No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Relationship Between Body Mass Index and Slipped Capital Femoral Epiphysis
Abstract
Slipped capital femoral epiphysis (SCFE) is the most common hip disorder of adolescents and is known to be strongly associated with obesity. The use of Body Mass Index (BMI) as an assessment of obesity has been shown to be a very efficient technique. The Centers for Disease Control & Prevention has recently developed BMI-for-age percentile growth charts that have been shown to effectively evaluate obesity in the pediatric population. In the current study, the investigators provide a retrospective review, looking at the association between SCFE and obesity based on BMI. One hundred six subjects with radiographically diagnosed SCFE were compared with 46 controls without radiographic evidence of SCFE. In the SCFE group, 81.1% of individuals had a BMI above the 95th percentile; for the control group, the corresponding figure was only 41.3% (P < 0.0001). Multiple linear regression analysis controlling both for sex and age confirmed an equally significant difference (P < 0.0001) between SCFE patients and controls with regard to BMI. Based on pediatric obesity criteria designating a weight above the 95th percentile as obese and a weight between the 85th and 95th percentile as "at risk" for obesity, clinicians can use BMI to define obesity, a highly modifiable risk factor for SCFE. Early intervention and lifestyle modifications may reduce the incidence of not only SCFE but other illnesses related to obesity as well.
... Manoff [11], Song [12], Madhuri [13] and Perry [14] conducted case-control studies which all found a significant difference between the Body Mass Index (BMI) of the epiphysiolysis group compared to the control group (p > 0.0001; p = 0.0078; p = 0.006) or compared to the British reference population. Obana et al. [15] evaluated the BMI of 275 children with SCFE and demonstrated how "normal-weight" SCFE patients are mainly found in older (p = 0.015), female (p = 0.034) patients, and present with a more severe (p = 0.007) and unstable (p = 0.001) slip than overweight and obese SCFE patients. ...
... Obesity increases the sheer force across the physeal plate, which causes repeated trauma to the physis and eventually causes the epiphysis to separate from the metaphysis. Although studies have linked obesity to an increased risk of SCFE, no research studies have examined whether there is a BMI limit beyond which a child's risk for SCFE increases [11]. Litchman et al. [34] hypothesised that anatomical abnormalities such as femoral and acetabular retroversion, and excessive acetabular coverage in combination with excessive loading, may generate sufficient shear forces to cause the slip. ...
... Litchman et al. [34] hypothesised that anatomical abnormalities such as femoral and acetabular retroversion, and excessive acetabular coverage in combination with excessive loading, may generate sufficient shear forces to cause the slip. The hypothesis has subsequently been supported by several studies [11,12,14,35] but this literature review analysis shows that in a total of 613 children [11,12,15] with SCFE, 299 (48.77%) were obese and 314 (51.22%) non-obese. ...
Slipped capital femoral epiphysis (SCFE) is the most common hip disorder affecting children and adolescents aged between 9 and 16 years, affecting approximately 10 per 100,000 children per year. The diagnosis of SCFE is often delayed, leading to an increased risk of complications. This study aims to provide the latest evidence concerning the causes of diagnostic delay and risk factors for SCFE and to educate general practitioners and paediatricians to help reduce delays in diagnosis and provide earlier therapeutic intervention. A literature search was conducted in the ScienceDirect and PubMed databases according to the PRISMA statement. Suitable studies for this systematic review included 22 articles discussing the aetiology of SCFE, risk factors, and causes of late diagnosis. Causes of delayed diagnosis include underestimation by patients, initial diagnostic approach by a non-orthopaedic professional, inadequate imaging, failure to recognize morphological changes, and variation in symptomatic presentation. The underlying risk factors for SCFE are likely part of a multifactorial process which involves anatomical variations and the metabolism of leptin, growth hormone, insulin, and other metabolic parameters. This review highlights the importance of early recognition and diagnosis of SCFE and proposes an algorithm for physicians to approach children who may have this condition.
... Previous studies have found that over 80% of patients with SCFE are considered obese, even when weight is corrected for height, age, and sex. [3][4][5][6][7][8] Numerous theories include mechanical and hormonal factors and have been proposed to explain this association. [9][10][11] Little data exist in the literature on patients with SCFE who are normal weight. ...
... Although SCFE has been associated with endocrinopathies, 18 renal disease, 19 growth hormone usage, 20 and prior radiation exposure to the area, it usually occurs in children who are without underlying risk factors, 12,19-21 except obesity. [3][4][5][6][7]12,[21][22][23][24][25] Previous studies have found that over 80% of patients with SCFE are considered obese by BMI percentile corrected for age and sex of greater than the 95th percentile. 7 Our study found a slightly lower rate of obesity in our SCFE patients with 70% of our patient population having a BMI of 95% or greater. ...
... [3][4][5][6][7]12,[21][22][23][24][25] Previous studies have found that over 80% of patients with SCFE are considered obese by BMI percentile corrected for age and sex of greater than the 95th percentile. 7 Our study found a slightly lower rate of obesity in our SCFE patients with 70% of our patient population having a BMI of 95% or greater. ...
Objective:
To evaluate rates and characteristics of slipped capital femoral epiphysis (SCFE) in children who are not obese to prevent missed diagnoses and subsequent complications.
Study design:
A multicenter, retrospective review identified all patients with SCFE from January 1, 2003 to December 31, 2012. Patients were excluded if they received previous surgery at an outside institution, had no recorded height and weight, or had medical co-morbidity associated with increased risk of SCFE. Body mass index (BMI) percentile for age was calculated and categorized for each patient (patients without obesity vs with obesity).
Results:
In total, 275 patients met inclusion criteria. Average BMI was 91.2 percentile (range: 8.4-99.7). Thirteen percent (34 patients) were considered "normal weight" (BMI 5%-85%), 17% (48 patients) were considered "overweight" (BMI 85%- 95%), and 70% (193 patients) were considered "obese" (BMI >95%). Average BMI percentile was higher in male than female patients (93.2 ± 12.7 vs 88.5 ± 21.4, P = .034). Patients without obesity were older compared with patients with obesity (12.2 ± 1.7 vs 11.7 ± 1.6 years, P = .015). Fewer patients without obesity were seen at the hospital in the southwest. The southwest had fewer patients without obesity the northeast (18.3% vs 36.1%, P = .002). Patients without obesity were more likely to present with a severe slip as graded by Wilson percent displacement (27.2% vs 11.4%, P = .007) and an unstable slip (32.9% vs 14.7%, P = .001).
Conclusion:
Rates of nonobese SCFE in this study are higher than reported in the previous literature. Normal weight patients with SCFE are more likely to be older, female, and present with a severe and unstable SCFE.
... Obesity has been shown to be a strong and validated risk factor for SCFE (12,13). Body Mass Index (BMI) >95th percentile for age and sex has a strong correlation with SCFE when compared to children with BMI <85th percentile for age and sex (14). Based on the rate of weight gain and the BMI, we decided to do prophylactic in situ pinning for the contralateral (left) hip to prevent SCFE (14). ...
... Body Mass Index (BMI) >95th percentile for age and sex has a strong correlation with SCFE when compared to children with BMI <85th percentile for age and sex (14). Based on the rate of weight gain and the BMI, we decided to do prophylactic in situ pinning for the contralateral (left) hip to prevent SCFE (14). ...
We report a case of slipped capital femoral epiphysis (SCFE), an on target skeletal toxicity of a pan-FGFR TKI inhibitor, erdafitinib. A 13-year-old boy was diagnosed to have an optic pathway/hypothalamic glioma with signs of increased intracranial pressure and obstructive hydrocephalus requiring placement of ventriculo-peritoneal (VP) shunt. Sequencing of the tumor showed FGFR1-tyrosine kinase domain internal tandem duplication (FGFR1-KD-ITD). He developed hypothalamic obesity with rapid weight gain and BMI >30. At 12 weeks of treatment with erdafitinib, he developed persistent knee pain. X-ray of the right hip showed SCFE. Erdafitinib was discontinued, and he underwent surgical pinning of the right hip. MRI at discontinuation of erdafitinib showed a 30% decrease in the size of the tumor, which has remained stable at 6 months follow-up. Our experience and literature review suggest that pediatric patients who are treated with pan-FGFR TKIs should be regularly monitored for skeletal side effects.
... In most cases the capital femoral epiphysis slides from the metaphysis in a medial-posterior direction (varus), but lateral-posterior displacements (valgus) are also described [2]. While an atypical type is caused by a known trigger including endocrine disorders, renal osteodystrophy or radiation treatment, the majority is idiopathic and only associated with general risk factors, especially obesity [3,4]. The affected children are on average between 11.7-13.0 ...
... [5]. Further, the mean BMI was 26.5 kg/m 2 and represents under recognition of the mean age a percentile value > 95.0%, which also was observed in other studies [4,33]. However, the focus of this retrospective study was the anatomy of the hip socket and the femoral head-neck junction over time after SCFE to determine the frequency of a FAI type cam and a trend to a more retroverted and dysplastic socket shape compared to the unaffected hip joint. ...
(1) Background: Previous studies have proven a high incidence of a femoro-acetabular impingement (FAI) type cam in patients sustaining a slipped capital femoral epiphysis (SCFE). Thus, the current study analyzed, if a cam deformity is predictable after SCFE treatment; (2) Methods: 113 cases of SCFE were treated between 1 January 2005 and 31 December 2017. The radiological assessment included the slip angle after surgery (referenced to the femoral neck (epiphyseal tilt) and shaft axis as Southwick angle) and the last available lateral center edge angle (LCEA), the acetabular- and alpha angle. A correlation was performed between these parameters and the last alpha angle to predict a FAI type cam; (3) Results: After a mean follow-up of 4.3 years (±1.9; 2.0–11.2), 48.5% of the patients showed a FAI type cam and 43.2% a dysplasia on the affected side. The correlation between the epiphyseal tilt and alpha angle was statically significant (p = 0.017) with a medium effect size of 0.28; (4) Conclusions: The postoperative posterior epiphyseal tilt was predictive factor to determine the alpha angle. However, the cut-off value of the slip angle was 16.8° for a later occurrence of a FAI type cam indicating a small range of acceptable deviations from the anatomical position for SCFE reconstruction.
... In a retrospective review, investigators found that 81.1% of children with SCFE had a BMI above the 95 th percentile (i.e. clinically obese) compared to only 41.3% of controls (P < 0.0001) (3) . ...
... The obesity had the effect of increasing the weight and cause shearing force across the growth plate of proximal femoral physis leading to progressive slippage of femoral head posterior and inferior in direction to weight-bearing force (3) . ...
... Lehmann et al. noted that the age of onset has been decreasing in recent years and considered whether earlier maturation might be the cause [5]. Another report indicates, however, that if earlier maturation is indeed the cause, the number of young patients should be higher, and suggests the possibilities of multifactorial causes [7]. Reports indicate that the probability of concomitant obesity is particularly high in young patients without obvious underlying disease or background factors [8][9]. ...
... Previous literature has identified obesity as the main risk factor for SCFE; overweight contributes to increased sheer stress across the physis. With regard to the relationship between the onset of SCFE and BMI, Poussa et al. reported that BMI could be a useful tool for evaluating the risk of SCFE [9], and Manoff et al. reported that 81.1% of 106 patients had a BMI that exceeded the 95th percentile [7]. In addition, Bhatia et al. reported that BMI was higher in patients with bilateral occurrence than those with unilateral occurrence [8]. ...
Slipped capital femoral epiphysis (SCFE) commonly occurs during puberty. Onset of SCFE at either less than 10 years old or over 16 years is defined as atypical. As in our patient, atypical onset at less than 10 years occurred in 9%, and the age of onset has been decreasing in recent years and that the probability of concomitant obesity is particularly high in young patients without obvious underlying disease or background factors. In the treatment of SCFE, preventing further slipping and permitting femoral bone growth by physeal closure is difficult, especially for young patients. We adopted 'dynamic single screw fixation' using SCFE short thread screw for continuous fixation without disturbing the growth of proximal femur or damaging to growth plate. Refixation was necessary once. The screw worked for 7 years 4 months while physeal closure was avoided. At the 10-year follow-up, her growth had stopped. She had no problem clinically, no increase in the posterior sloping angle (PSA), and no obvious growth disturbance of the femur.
... Being overweight and obese is a risk factor for having SCFE during adolescence, as the literature widely supports [8][9][10][11]. ...
... It is widely accepted that being overweight or obese increases the risk of SCFE in adolescents, with many being above the 95 th percentile of BMI-for-age [9][10][11][26][27][28]. This may be due to the increased shear stresses on the physis [29]. ...
... 1,2 Prepubescent obesity is directly associated with SCFE. [3][4][5][6] However, only in 5% to 8% of cases debilitating endocrine alterations of the physis, such as hypothyroidism, growth hormone deficiency, hypogonadism, and parathyroid hormone alterations are found. 2,7,8 This inconstancy contributes to obesity being considered a mechanical factor in the pathogenesis of SCFE. ...
... Approximately 80% of patients with SCFE are obese. [3][4][5] To associate SCFE with the risk of T2DM, Ucpunar and colleagues compared HbA1c in patients with SCFE and obese patients of the same age. Of 51 patients with SCFE, 43 were not at risk of T2DM, 7 were at risk, and 1 was diagnosed with T2DM. ...
Background:
Obesity in the prepuberal stage has been directly associated with slipped capital femoral epiphysis (SCFE). Serum insulin level increases in the prepuberal and adolescence stage, to a greater extent in the obese population. The main objective of this article was to analyze the relationship between insulin levels and SCFE.
Methods:
A case-control study was conducted between January 2018 and April 2019. The study group was formed with patients with SCFE and the control group with patients from the pediatric obesity clinic of our hospital selected during their initial evaluation. None were being treated for obesity. Anthropometric measurements of size, weight, waist circumference, and blood pressure were taken. Body mass index (BMI) and waist-height index of all patients were calculated. According to BMI for age, they were classified as normal, overweight, or obese. Serum determinations of glucose, insulin, glycated hemoglobin, lipid profile, and complete blood count were analyzed. Insulin resistance was diagnosed with Homeostatic Model Assessment (HOMA) >3. Insulin levels >13 U/mL for girls and >17 U/mL for boys were considered as hyperinsulinemia.
Results:
We studied 14 patients with SCFE and 23 in the control group. The mean age and BMI in both groups were similar. The elevation of serum insulin was significantly higher in the SCFE group (P=0.001) as was HOMA (P=0.005). Triglycerides and very-low-density lipoprotein were higher in the SCFE group (P=0.037 and 0.009, respectively). Glycemia, glycated hemoglobin, total cholesterol, high-density lipoprotein, low-density lipoprotein, and neutrophils showed no significant difference.
Conclusions:
Patients with SCFE showed elevated levels of insulin, HOMA, triglycerides, and very-low-density lipoprotein, even higher than the control group. Our study demonstrates a significant association between abnormally high serum insulin levels and SCFE. The known effects of insulin on growth cartilage may explain the physeal mechanical insufficiency to support the abnormally high or repetitive loads in accelerated growth stages that lead to SCFE.
Level of evidence:
Level III-case-control, prognostic study.
... [5] A high prevalence of obesity were noted among patients with SCFE. In fact, a study revealed that 80% of the patient with SCFE are diagnosed with obesity as well [6] Obesity can increase the mechanical load over the proximal femur. [7] Also, a study noted that patients with obesity have lower degree of proximal femur anteversion and vertical femur physis which increases the chance of the slippage. ...
Background
Slipped capital femoral epiphysis (SCFE) is usually seen in patients with high body mass index (BMI) and endocrine diseases. SCFE is exceedingly rare among Cerebral palsy (CP) patients due to spasticity present in those patients. Percutaneous in situ fixation is the treatment option for SCFE patients. According to the literature, there’s no single case report with SCFE in a spastic CP patient with no prior history of trauma, seizure episodes, or endocrine disease.
Case presentation
We report a case of an 11-year-old spastic cerebral palsy (CP) patient with a physical status of level 5 motor function on the gross motor function classification system. He was brought by his mother to the clinic complaining of bilateral hip pain. The mother denied any history of trauma or any seizure episodes. The pain had started spontaneously. Physical examination showed severe spasticity and bilateral hip abduction with external rotation. Drehmann’s sign was positive. Bilateral hip radiographs revealed bilateral partial open femoral capital physis with evidence of SCFE bilaterally. Also, the Southwick angle was measured, and it was severe. The patient was taken to the operating room and treated with closed reduction and percutaneous in situ fixation. He was seen multiple times following surgical intervention, reporting pain relief, and showing complete wound healing.
Conclusion
This report concludes that paraplegic spastic CP patients may present with SCFE spontaneously without trauma, seizures, or an underlying endocrine disease. Also, severe spasticity might potentially be a risk factor for SCFE, although further investigations would be necessary to establish a conclusive link.
... There is a well-documented link between BMI and SCFE. In a study analyzing the BMI of SCFE patients compared to non-SCFE controls, the SCFE group had 81.1% of individuals with a BMI above the 95th percentile compared to 41.3% in the control group [101]. When compared to children of the same age, children with severe obesity had a 5.9 times higher risk of SCFE at ages 5 to 6, and a 17 times higher risk at ages 11 to 12 [102]. ...
Longitudinal bone growth is mediated through several mechanisms including macro- and micronutrients, and endocrine and paracrine hormones. These mechanisms can be affected by childhood obesity as excess adiposity may affect signaling pathways, place undue stress on the body, and affect normal physiology. This review describes the physiology of the epiphyseal growth plate, its regulation under healthy weight and obesity parameters, and bone pathology following obesity. A literature review was performed utilizing PubMed, PMC, NIH, and the Cochrane Database of Systematic Reviews pertinent to hormonal and nutritional effects on bone development, child obesity, and pathologic bone development related to weight. The review indicates a complex network of nutrients, hormones, and multi-system interactions mediates long bone growth. As growth of long bones occurs during childhood and the pubertal growth spurt, pediatric bones require adequate levels of minerals, vitamins, amino acids, and a base caloric supply for energy. Recommendations should focus on a nutrient-dense dietary approach rather than restrictive caloric diets to maintain optimal health. In conclusion, childhood obesity has profound multifaceted effects on the developing musculoskeletal system, ultimately causing poor nutritional status during development. Weight loss, under medical supervision, with proper nutritional guidelines, can help counteract the ill effects of childhood obesity.
... Morphological differences have also been documented between the femora of higher BMI children and adolescents compared to their lower BMI peers. Higher BMI individuals have a higher incidence of slipped capital femoral epiphysis (Manoff et al., 2005) and a reduced epiphyseal tubercle (Hosseinzadeh et al., 2020). Children with higher BMI also have a significantly lower femoral anteversion angle, which manifests as high external rotation of lower limb (i.e., high foot progression angle; Galbraith et al., 1987;Wearing et al., 2006). ...
Bone functional adaptation is routinely invoked to interpret skeletal morphology despite ongoing debate regarding the limits of the bone response to mechanical stimuli. The wide variation in human body mass presents an opportunity to explore the relationship between mechanical load and skeletal response in weight‐bearing elements. Here, we examine variation in femoral macroscopic morphology as a function of body mass index (BMI), which is used as a metric of load history. A sample of 80 femora (40 female; 40 male) from recent modern humans was selected from the Texas State University Donated Skeletal Collection. Femora were imaged using x‐ray computed tomography (voxel size ~0.5 mm), and segmented to produce surface models. Landmark‐based geometric morphometric analyses based on the Coherent Point Drift algorithm were conducted to quantify shape. Principal components analyses were used to summarize shape variation, and component scores were regressed on BMI. Within the male sample, increased BMI was associated with a mediolaterally expanded femoral shaft, as well as increased neck‐shaft angle and decreased femoral neck anteversion angle. No statistically significant relationships between shape and BMI were found in the female sample. While mechanical stimulus has traditionally been applied to changes in long bong diaphyseal shape it appears that bone functional adaptation may also result in fundamental changes in the shape of skeletal elements.
... [1][2][3][4] Previous epidemiological studies have reported the incidence of SCFEs in the United States to be approximately 10 to 11 per 100,000, 3,5,6 with this incidence rising over recent decades likely as a result of rising rates of obesity and earlier skeletal maturation in this population. 2,7,8 The pathogenesis of the slip is often thought to be caused by a mechanical overloading of the femoral head that leads to a slip through the relatively weaker hypertrophic zone of the physeal cartilage during adolescence. 4 Rapid identification and treatment of a slip is paramount to prevent severe consequences such as femoral head-neck deformities and osteonecrosis of the femoral head due to blood supply disruption. ...
Introduction
The purpose of this study was to describe proximal femoral deformity after contralateral hip prophylactic fixation of slipped capital femoral epiphysis (SCFE) in patients and the association of relative skeletal immaturity with this deformity.
Methods
A retrospective review of patients presenting with a SCFE was conducted from 2009 to 2015. Inclusion criteria were (1) radiographic evidence of a unilateral SCFE treated with in situ fixation, (2) contralateral prophylactic fixation of an unslipped hip, and (3) at least 3 years of follow-up. Measurements were made on radiographs and included greater trochanter height relative to the center of the femoral head, femoral head-neck offset, and femoral neck length. Skeletal maturity was evaluated by assessing the status of the proximal femoral physis and triradiate cartilage (TRC) of the hip, in addition to the length of time to closure of these physes. Values were compared from initial presentation to final follow-up. Statistical analysis included descriptive statistics and linear regression.
Results
Twenty-seven patients were included. Bivariable linear regression demonstrated that an increased relative trochanteric overgrowth was associated with TRC width (β = 3.048, R = 0.585, P = 0.001) and an open TRC (β = −11.400, R = 0.227, P = 0.012). Time to proximal femoral physis closure (β = 1.963, R = 0.444, P = 0.020) and TRC closure (β = 1.983, R = 0.486, P = 0.010) were predictive of increased deformity. In addition, multivariable elimination linear regression demonstrated that TRC width (β = 3.048, R = 0.585, P = 0.001) was predictive of an increased relative trochanteric overgrowth.
Discussion
Patients with an open TRC and increased TRC width are associated with increased relative trochanteric overgrowth when undergoing prophylactic fixation for a unilateral SCFE. Increased caution should be exercised when considering contralateral hip prophylactic fixation in skeletally immature patients presenting with a unilateral SCFE.
Level of evidence
Level IV, case series.
... Previous studies have been small single institution cohorts that are difficult to generalize trends that lend causation of pathology. [19][20][21][22] According to the National Health and Nutrition Examination Survey (NHANES), 23 24 The obesity rate was 19.3% (1.0), including a severe obesity rate of 6.1% (0.7) for ages 2-19. 24 Recent studies have suggested a divergent relationship between SCFE incidence and increasing obesity rates. ...
Background: Slipped capital femoral epiphysis (SCFE) is a common hip pathology affecting adolescents mostly in the rapid growth phase. Previous studies have presented epidemiological data to inform practitioners of its etiology to improve diagnosis, treatment, and prevention. However, in recent years, national databases have been redesigned, which may change previously published information on SCFEs. The purpose of this study is to evaluate SCFE epidemiology using the Healthcare Cost and Utilization Project (HCUP) and Kids’ Inpatient Database in conjunction with U.S. Census Data. Methods: The Kids’ Inpatient Database reflects data on 5.9 million pediatric discharges in 2019 and was combined with U.S. Census data to produce epidemiologic data regarding SCFEs in the pediatric population. KID regional data was then overlayed with National Oceanographic and Atmospheric Administration (NOAA) data to assess the associations between climate patterns and UV indices with SCFE incidence. Results: Overall incidence of SCFE in the U.S. was 2.66/100,000 children 9-16 years of age. The average age at presentation with SCFE was 12.3 years with males being older at presentation (12.8 vs. 11.6 years; P<.001; r=0.34). Males were significantly more likely to develop a SCFE than females (OR 1.73; 95% CI, 1.51-1.97). Black patients were significantly more likely to present with a SCFE than all other races (OR 1.66; 95% CI, 1.40 to 2.97). Obesity (23.2%) was the most common metabolic and endocrine comorbidity followed by severe obesity (7.5%). Geographical regions with colder temperatures and lower UV indexes had higher SCFE rates, while regions with higher temperatures and higher UV indexes had lower SCFE rates. Conclusion: This study determined a lower SCFE incidence rate than previously reported but shows similar distributions of SCFEs amongst different races. Age of onset was increased compared to previous studies. The rate of obesity also continues to increase while the incidence of SCFEs has experienced a gradual decrease over time. It is plausible that environmental factors and race (skin tone) may have a more influential effect on the development of this pathology.
... Slipped capital femoral epiphysis (SCFE) is a prevalent hip disorder in adolescents, where the growth plate, also known as physis, is disrupted and the metaphysis, the part of the bone located next to the growth plate, displaces in a posterior-inferior direction with respect to the capital femoral epiphysis (i.e., femoral head) (Manoff et al., 2005;Novais and Millis, 2012). Obesity, endocrine disorders, oblique physeal growth, and increased femoral retroversion increase the risk of SCFE due to either a weakening (endocrine) of the growth plate or an increased mechanical stress on the growth plate (Perry et al., 2018;Herngren et al., 2017;Wylie and Novais, 2019). ...
... Although the exact mechanisms through which obesity predisposes adolescents to the disease are not yet fully understood, evidence linking obesity with idiopathic SCFE have been provided through observational studies [67,68], case series [69,70], mathematical models [39,71,72], and population-based epidemiologic cohorts [1,14,32], where a strong association has been demonstrated. Non-obese children presenting with the disease are more likely to suffer an atypical, unstable, and more severe slip [30]. ...
Slipped capital femoral epiphysis (SCFE) is the most common adolescent hip disorder in children 9-15 years old with an incidence that ranges from 0.33:100,000 to 24.58:100,000. Idiopathic SCFE is strongly associated with obesity, while atypical SCFE is associated with endocrinopathies, metabolic and renal disease, radiation therapy, and chemotherapy. In this review, we summarized the current data regarding the pathogenesis of SCFE and its association to obesity. In the last years, there have been increasing evidence regarding the implication of obesity in the pathogenesis of SCFE, but no definitive mechanism has been proven. The etiology is probably multifactorial, with both mechanical and metabolic factors contributing to the disease, with the later gaining more ground, especially in obese patients. Understanding what causes the disease will help paediatricians and orthopaedists develop more efficient strategies for treating patients and diminishing complication rates.
... The BMI is a value calculated by weight divided by height squared and is an objective and consistent parameter with high sensitivity and specificity that can be successfully employed to categorize obese and non-obese patients for clinical measurement [20,21]. The BMI percentile for age is an indicator that displays height and weight scales depending on age on the same graph. ...
Background: Slipped capital femoral epiphysis (SCFE) is a hip disorder that occurs in adolescence before epiphyseal plate closure, causing anatomical changes in the femoral head. Obesity is known to be the single most important risk factor for idiopathic slipped capital femoral epiphysis (SCFE), which is highly related to mechanical factors. Meanwhile, as increased slip angle increases major complications in patients with SCFE, slip severity is an important factor to evaluate prognosis. In obese patients with SCFE, higher shear stress is loaded on the joint, which increases the likelihood of slip. The study aim was to assess the patients with SCFE treated with in situ screw fixation according to the degree of the obesity and to find any factors affecting the severity of slip. Methods: Overall, 68 patients (74 hips) with SCFE who were treated with in situ fixation screw fixation were included (mean age 11.38, range: 6–16) years. There were 53 males (77.9%) and 15 females (22.1%). Patients were categorized underweight, normal weight, overweight, and obese depending on BMI percentile for age. We determined slip severity of patients using the Southwick angle. The slip severity was defined as mild if the angle difference was less than 30 degrees, moderate if the angle difference was between 30 and 50 degrees, and severe if the angle difference was greater than 50 degrees. To examine the effects of several variables on slip severity, we used a univariable and multivariate regression analysis. The following data were analyzed: age at surgery, sex, BMI, symptom duration before diagnosis (acute, chronic, and acute on chronic), stability, and ability to ambulate at the time of the hospital visit. Results: The mean BMI was 25.18 (range: 14.7–33.4) kg/m2. There were more patients with overweight and obese than those with normal weight in SCFE (81.1% vs. 18.9%). We did not find significant differences between overall slip severity and degree of obesity or in any subgroup analysis. Conclusions: We did not find a relationship between slip severity and degree of obesity. A prospective study related to the mechanical factors affecting the slip severity according to the degree of obesity is needed.
... The pathogenesis of cam deformity and SCFE are multifactorial. However, mechanical factors, mainly early participation in high-impact sports (e.g., soccer, ice-hockey and basketball) and obesity, seem to play a determinant role [10][11][12][13][14]. There is also a growing body of evidence suggesting shared etiologies and sequelae in cam deformity and SCFE [15][16][17]. ...
Introduction
The deleterious influence of increased mechanical forces on capital femoral epiphysis development is well established; however, the growth of the physis in the absence of such forces remains unclear. The hips of non-ambulatory cerebral palsy (CP) patients provide a weight-restricted (partial weightbearing) model which can elucidate the influence of decreased mechanical forces on the development of physis morphology, including features related to development of slipped capital femoral epiphysis (SCFE). Here we used 3D image analysis to compare the physis morphology of children with non-ambulatory CP, as a model for abnormal hip loading, with age-matched native hips.
Materials and methods
CT images of 98 non-ambulatory CP hips (8–15 years) and 80 age-matched native control hips were used to measure height, width, and length of the tubercle, depth, width, and length of the metaphyseal fossa, and cupping height across different epiphyseal regions. The impact of age on morphology was assessed using Pearson correlations. Mixed linear model was used to compare the quantified morphological features between partial weightbearing hips and full weightbearing controls.
Results
In partial weightbearing hips, tubercle height and length along with fossa depth and length significantly decreased with age, while peripheral cupping height increased with age (r > 0.2, P < 0.04). Compared to normally loaded (full weightbearing) hips and across all age groups, partially weightbearing hips’ epiphyseal tubercle height and length were smaller (P < .05), metaphyseal fossa depth was larger (P < .01), and posterior, inferior, and anterior peripheral cupping heights were smaller (P < .01).
Conclusions
Smaller epiphyseal tubercle and peripheral cupping with greater metaphyseal fossa size in partial weightbearing hips suggests that the growing capital femoral epiphysis requires mechanical stimulus to adequately develop epiphyseal stabilizers. Deposit low prevalence and relevance of SCFE in CP, these findings highlight both the role of normal joint loading in proper physis development and how chronic abnormal loading may contribute to various pathomorphological changes of the proximal femur (i.e., capital femoral epiphysis).
... SCFE is associated with obesity. 1,2,[17][18][19][20] The cause of this obesity in SCFE children has not yet been explored and is likely multifactorial; 1 explanation is residence in a food desert. This study explored the prevalence of Indiana SCFE patients living in food deserts compared with the overall Indiana population and found that SCFE patients more commonly lived in food deserts. ...
Background:
Childhood obesity is increased in food deserts, a community with little to no access to healthy food. As obesity is associated with slipped capital femoral epiphysis (SCFE), it was the purpose of this study to analyze the prevalence of SCFE patients by food desert location and its interaction with rural/urban location.
Methods:
A retrospective review of all consecutive patients with idiopathic SCFE treated at our institution over 11 years was performed. From the patient's address, the US Census Bureau tract in which the patient resided was determined. Using the census tract code, it was ascertained if the patient lived in a food desert and urban or rural location. Standard statistical analyses were performed; a P<0.05 was considered statistically significant.
Results:
There were 177 SCFE patients: 79 girls, 98 boys, 106, White, and 69 nonWhite. The average age at diagnosis was 12.1±1.7 years, the average symptom duration 4.1±5.1 months, and the average weight percentile 94±10. Of these 177 patients, 26.5% lived in a food desert, which was higher than the expected 17.5% (P=0.023). Those living in a food desert were more commonly nonWhite (60% vs. 32%, P=0.0014). There were 25% from rural areas and 75% from urban areas. No rural SCFE patients lived in food deserts whereas 34% of urban patients lived in food deserts. The average poverty rate of the SCFE patient census tracts was 19%, no greater than the expected 15% (P=0.32). SCFE patients living in rural census tracts had a lower poverty rate (P<10-6).
Conclusions:
There is a correlation with the prevalence of SCFE patients by residence in a "food desert", but not with rural/urban locale or poverty status in Indiana. Further research will be needed to see if these findings apply to other states within the United States and other parts of the world.
Level of evidence:
III.
... While the strong association of obesity and SCFE has been well-studied, 7,9,10 there is a growing body of literature highlighting the role of both clinical and subclinical endocrinopathies in weakening of the capital femoral physis leading to SCFE. Clinical endocrinopathies that have historically been associated with SCFE include renal osteodystrophy, hypothyroidism, panhypopituitarism, and growth hormone replacement or excess. ...
Purpose: The purpose of this review is to discuss the insights into slipped capital femoral epiphysis (SCFE) gained during the last decade, including a proposed rotational pathomechanism, the importance of epiphyseal morphology, subclinical endocrinopathies and atypical SCFE, and updates to current management practices. Pathophysiology: Growing literature has highlighted the importance of the epiphyseal tubercle as a ‘keystone’ stabilizer of the proximal femoral epiphysis. Both anatomic and clinical studies recently demonstrated that the epiphysis rotates around the epiphyseal tubercle during SCFE. Clinical endocrinopathies contribute to the pathogenesis of SCFE, though recently the effects of subclinical endocrine derangements such as hyperinsulinism and leptin abnormalities have been demonstrated to play a role in SCFE. Diagnosis: The standard diagnostic tools for SCFE remain the antero-posterior pelvis and frog-leg lateral radiograph. The importance of imaging bilateral hips is well known, due to the increased incidence of contralateral slip development in SCFE patients. Additionally, due to increased knowledge of atypical SCFE, patients with positive age-weight or age-height testing are also recommended to undergo further endocrine workup due to the high likelihood of atypical SCFE in these patients. Management: In-situ pinning remains the gold standard treatment of SCFE. Use of two-screws is mainly reserved for unstable or severe slips, while one-screw fixation remains the standard for mild-moderate slips. Contralateral prophylactic pinning is typically considered in those patients at high risk for contralateral slip, including those with endocrine risk factors, skeletal immaturity via modified oxford bone age, or aberrant radiographic parameters such as posterior epiphyseal tilt or posterior sloping angle. Novel techniques including intraoperative epiphyseal perfusion monitoring have provided insight into reducing complications such as avascular necrosis and have shown the benefit of intracapsular hematoma decompression for unstable SCFE. Open surgical management via the modified Dunn procedure should be cautiously considered, as high rates of osteonecrosis have been reported due to the vulnerable blood supply of the proximal femoral head.
... Though I do not have strong supporting data, I did observe that slipped capital femoral epiphysis (SCFE) often occurred in relatively tall and thin adolescent boys and girls, unlike the patients that the Western literature describes as obese. [13][14][15] These patients also presented at an older age, 15-16 years old, than described in the literature. I do hypothesize that skeletal ages described in Western literature are not always generalizable to other populations. ...
This article shares the perspective and experience of an early career pediatric orthopaedic surgeon at a mission hospital in Kenya, where she spent nearly her first three years in practice. She shares the reasoning behind her decision to engage in full-time global orthopaedics work as well as some of the logistical aspects of planning for the transition to international practice. Trauma, osteomyelitis, and COVID-19 are focal points of sharing her experience. The role of historical social and political injustice and its contribution to local and global health inequity is explored, emphasizing the importance of simultaneously pursuing global and local health justice.
... It is conceivable that deficiencies in the development of the subchondral bone plate and mammillary processes may result in weakening of the interface and could contribute to conditions such as slipped capital femoral epiphysis (SCFE). SCFE is characterized by a non-traumatic displacement of the femoral metaphysis with respect to the capital femoral epiphysis through failure of the physis and is believed to have a multifactorial etiology involving biomechanical, biochemical, endocrine and developmental factors [5,6,7,8,9]. ...
Background. The subchondral epiphyseal bone plate
between the epiphysis and the growth plate cartilage is formed
by an unknown process. Objective. To examine if reserve zone
chondrocytes could be involved in the development of the subchondral
epiphyseal bone plate, by relating their intracellular stress-strain
state to mechanobiological tissue differentiation theories. Methods.
Multiscale elastic finite element models of the porcine proximal
femoral physis at 20, 35, and 480 days after birth were created, based
on histological observations. Findings. Simulating 15% compression
of the growth plate produced intracellular maximum principal strains
of 0.1–15% and compressive hydrostatic stresses of 0.15–0.4MPa,
depending on age and depth within the reserve zone. These values
are within the range known to correspond with endochondral bone
formation in fracture healing. Near the epiphyseal bone border the
values for cellular compressive hydrostatic stress (> 0.15MPa) and
maximum tensile strain (0.1%) fall in the same range as found for
hypertrophic chondrocytes at the metaphyseal bone growth front.
Conclusion. The evidence suggests that growth plate cartilage has
a secondary growth front at the reserve zone-epiphysis border that
contributes to forming the subchondral epiphyseal bone plate.
... It is more common among obese adolescents. [1] Bilateral SCFE has been reported in the literature between 20-80%. [2] Endocrine pathologies, genetic factors and mechanical factors such as trauma, obesity, inflammatory diseases, chronic renal failure, hypothyroidism and hypopituitarism may be involved in the etiology of the disease. ...
Objective: Most of the previous studies have shown good functional outcomes for most patients after in situ pinning or pinning with anatomical reduction of slipped capital femoral epiphyses (SCFE). We undertook a retrospective study to document comparative outcomes of both treated groups of 25 SCFE patients.
Methods: Between 2005 and 2013, 21 patients (26 hips) with SCFE underwent in situ pin- ning or pinning with anatomical reduction at a tertiary referral center. Medical records and radiographs were reviewed for slip characteristics. Magnetic resonance imaging (MRI) was performed to all patients at final visits. Mean follow-up was 139 months (range, 64 to 179).
Results: There was no significant difference between in situ group and reduction group regarding range of motion (ROM), Visual Analog Scale (VAS), and Harris Hip Score (HHS) of hip (p>0.05). Mean outcome scores were; HHS 80.4, and VAS 2.9 respectively.
Conclusion: Especially in the anatomic reduction group, a decrease in hip ROM was ob- served (not statistically significant) compared to the in situ group. MRI revealed atrophy of the peri-hip musculature in the reduction group. This present study may suggest that patients with SCFE whether anatomically reduced or in situ pinned may not contribute to clinical outcomes.
... The first correlation between high BMI and increased rate of SCFE was in 2003 by Poussa et al. [56]. Since then, there have been other studies showing similar results [57,58] and that the severity of SCFE increases as BMI increases [59], while the incidence of bilaterally SCFE also increases [60]. There are conflicting reports if SCFE is related to vitamin D intake [61], and yet, a new study shows an association between elevated serum leptin levels and SCFE, regardless of BMI [62]. ...
Globally, obesity is on the rise with ~ 30% of the world's population now obese, and childhood obesity is following similar trends. Childhood obesity has been associated with numerous chronic conditions, including musculoskeletal disorders. This review highlights the effects of childhood adiposity on bone density by way of analyzing clinical studies and further describing two severe skeletal conditions, slipped capital femoral epiphysis and Blount's disease. The latter half of this review discusses bone remodeling and cell types that mediate bone growth and strength, including key growth factors and transcription factors that help orchestrate this complex pathology. In particular, the transcriptional factor peroxisome proliferator-activated receptor gamma (PPARγ) is examined as it is a master regulator of adipocyte differentiation in mesenchymal stem cells (MSCs) that can also influence osteoblast populations. Obese individuals are known to have higher levels of PPARγ expression which contributes to their increased adipocyte numbers and decreased bone density. Modulating PPAR*gamma* signaling can have significant effects on adipogenesis, thereby directing MSCs down the osteoblastogenesis pathway and in turn increasing bone mineral density. Lastly, we explore the potential of PPARγ as a druggable target to decrease adiposity, increase bone density, and be a treatment for children with obesity-induced bone fractures.
... The Rohrer index was significantly higher in group 1 than in groups 2 and 3. This is compatible with the report that obesity is a risk factor for SCFE 18) . Prophylactic contra-lateral side pinning should be considered in obese patients. ...
Background: The use of prophylactic contralateral pinning for slipped capital femoral epiphysis (SCFE) remains controversial. This study evaluated the outcome of SCFE treatment and examined the use of prophylactic pinning.
Methods: The study included 44 patients (33 men, 11 women; 54 hips [right, 31; left, 23]), with mean age of 12.9 (7.3–29) years, who underwent treatment between 1986 and 2017, with follow-up for more than 6 months. Patients were divided into 3 groups: group 1 had bilateral SCFE at first presentation, group 2 developed contralateral side SCFE during follow-up, and group 3 had unilateral SCFE until final follow-up. Three patients who received prophylactic pinning were excluded. Univariate and multivariate logistic analyses were performed.
Results: Overall, 93% (50/54) of hips underwent positional reduction and in situ fixation and 7.4% (4/54) underwent open reduction. Mean follow-up period was 4.8 (0.5–25) years. Groups 1, 2, and 3 had 7, 3, and 31 cases, respectively. Sex, age, and follow-up period showed no significant differences among the groups. The Rohrer index was significantly higher in group 1, the affected side posterior sloping angle (PSA) was significantly higher in group 3, and the contralateral side PSA and percentage with endocrinopathy were significantly higher in group 2. In multivariate logistic analysis, age, sex, Rohrer index, affected side PSA, and endocrinopathy were significantly correlated with bilateral SCFE.
Conclusion: We recommend prophylactic contralateral side pinning in patients with risk factors of obesity, high PSA before slipping, and endocrinopathy. Careful observation until growth plate closure is required in patients without risk factors.
... Other factors that favor prophylactic stabilization of the contralateral hip are: obesity (BMI >95th,>35kg/m2), young age (girls <10 years, boys <12 years), female gender, endocrine disorders [20,90,94,95,96,97]. ...
... It commonly affects adolescents due to the rapid skeletal growth, weight gain, and activity levels that stress the physis during this period of development. Obesity is the most common risk factor identified [28]. Patients younger than 10 years of age and older than 16 years of age are more likely to have secondary SCFE from an underlying disorder. ...
Purpose of Review
To review slipped capital femoral epiphysis (SCFE), with a focus on new insights into its etiology and evolving methods of operative fixation.
Recent Findings
The epiphyseal tubercle and its size during adolescence are paramount to understanding the mechanism of SCFE. In chronic stable SCFE, the epiphysis rotates about the tubercle protecting the lateral epiphyseal vessels from disruption. In an acute unstable SCFE, the tubercle displaces, increasing the risk of osteonecrosis, also known as avascular necrosis (AVN). Intraoperative stability suggests that stable and unstable SCFE based on ambulation may be inaccurate. For stable SCFE, in situ pinning remains the most accepted treatment for mild slips with delayed symptomatic femoroacetabular impingement (FAI) management. Treatment of moderate to severe stable slips with realignment osteotomy leads to less femoral deformity and potentially better outcomes. However, it has a higher risk of complications, including AVN and chondrolysis.
Summary
Our knowledge of the etiology for SCFE is evolving. The optimal technique for operative treatment of moderate to severe SCFE is controversial and varies by center. Well-controlled studies of these patients are needed to understand the best treatment for this difficult problem. Furthermore, increasing the awareness about SCFE is paramount to allow for early recognition and treatment of deformity at its early stages and avoiding severe SCFE deformity which has been associated with worse long-term outcomes.
... Previous case series from specialist centers have revealed an association between SCFE and obesity, 12,13,19 although these studies suffered from referral bias and poor generalizability to the wider population. Furthermore, the temporal relationship between the disease and obesity has been difficult to establish (ie, did children become obese because of hip disease, or did hip disease develop because of obesity). ...
: media-1vid110.1542/5828355774001PEDS-VA_2018-1067Video Abstract BACKGROUND: Slipped capital femoral epiphysis (SCFE) is believed to be associated with childhood obesity, although the strength of the association is unknown.
Methods:
We performed a cohort study using routine data from health screening examinations at primary school entry (5-6 years old) in Scotland, linked to a nationwide hospital admissions database. A subgroup had a further screening examination at primary school exit (11-12 years old).
Results:
BMI was available for 597 017 children at 5 to 6 years old in school and 39 468 at 11 to 12 years old. There were 4.26 million child-years at risk for SCFE. Among children with obesity at 5 to 6 years old, 75% remained obese at 11 to 12 years old. There was a strong biological gradient between childhood BMI at 5 to 6 years old and SCFE, with the risk of disease increasing by a factor of 1.7 (95% confidence interval [CI] 1.5-1.9) for each integer increase in BMI z score. The risk of SCFE was almost negligible among children with the lowest BMI. Those with severe obesity at 5 to 6 years old had 5.9 times greater risk of SCFE (95% CI 3.9-9.0) compared with those with a normal BMI; those with severe obesity at 11 to 12 years had 17.0 times the risk of SCFE (95% CI 5.9-49.0).
Conclusions:
High childhood BMI is strongly associated with SCFE. The magnitude of the association, temporal relationship, and dose response added to the plausible mechanism offer the strongest evidence available to support a causal association.
... Children with obesity (> 80 th centile) are predisposed to SCFE. (Manoff, Banffy et al. 2005) SCFE is typically seen during the time of adolescent growth spurt between 10 to 16 years of age. Moreover, some anatomical changes such as retroversion of > 10 ° and the inclination of the growth plate of the proximal femur increase the net effect of shear forces across the growth plate and predispose to slippage. ...
Slipped capital femoral epiphysis (SCFE) is common paediatric orthopaedic problem
that attract substantive research and debate. Understanding and subsequent treatments
is evolving at a high pace. Some forms of treatments have become obsolete and a new
surgical techniques have emerged and widely adopted without clear evidence of the
long term outcomes. This chapter examines the current practice, evidence that
underpin it and future research direction
Purpose
Slipped capital femoral epiphysis (SCFE) is a prevalent pediatric hip disorder linked to severe complications, with childhood obesity as a crucial risk factor. Despite the rising obesity rates, contemporary data on SCFE's epidemiology remain scarce in the United States. This study examined SCFE incidence trends and demographic risk factors in the United States over a decade.
Methods
A decade-long (2011 to 2020) retrospective cohort study was undertaken using the Healthcare Cost and Utilization Project National Inpatient Sample. Patients aged younger than 18 years were identified and further analyzed if diagnosed with SCFE through ICD-9 or ICD-10 codes. Key metrics included demographics variables, with multivariate regression assessing demographic factors tied to SCFE, and yearly incidence calculated.
Results
Of 33,180,028 pediatric patients, 11,738 (0.04%) were diagnosed with SCFE. The incidence escalated from 2.46 to 5.96 per 10,000 children, from 2011 to 2020, mirroring childhood obesity trends. Lower socioeconomic status children were predominantly affected. Multivariate analysis revealed reduced SCFE risk in female patients, while Black and Hispanic ethnicities, alongside the Western geographic location, had an increased risk.
Conclusion
This study underscores a twofold increase in SCFE incidence over the past decade, aligning with childhood obesity upsurge. Moreover, SCFE disproportionately affects lower SES children, with male sex, Black and Hispanic ethnicities amplifying the risk. This calls for targeted interventions to mitigate SCFE's effect, especially amidst the vulnerable populations.
We aimed to investigate the national trends in the incidence and management of slipped capital femoral epiphysis (SCFE) and to report the need for reoperations. We included all <19-year-old patients hospitalised for SCFE in 2004-2014 in mainland Finland (n=159). Data from the Finnish Care Register for Health Care, Statistics Finland, and Turku University Hospital patient charts were analyse for the incidence of SCFE in 2004-2012, the length of stay, and the type of surgery with respect to age, gender, study year, and season. The reoperations and rehospitalisations in 2004-2014 for SCFE were analysed for 2-10 years after surgery. In 2004 to 2012, primary surgery for SCFE was performed for 126 children. The average annual incidence of SCFE was 1.06/100 000 (95% confidence interval [CI], 0.81-1.38) in girls and 1.35/100 000 (95% CI 1.07-1.70) in boys. The median age at surgery was lower in girls than in boys (11 and 13 years, respectively, p<0.0001). During the study period, there was no significant change in the incidence of SCFE (p=0.9330), the type of primary procedures performed (p=0.9988), or the length of stay after the primary procedure (p=0.2396). However, the length of stay after percutaneous screw fixation was shorter compared with open reduction and fixation (mean 3.4 and 7.9 days, respectively, p<0.0001). There was no significant difference in the rate of reoperations according to the type of primary surgery. In conclusion, the incidence of SCFE and the proportion of different primary surgeries have recently remained stable in Finland.
Background
Slipped capital femoral epiphysis (SCFE) is a disorder of the proximal femoral physis occurring in late childhood and adolescence. Previously postulated risk factors include obesity and endocrinopathies. The purpose of this investigation was to identify risk factors for developing SCFE, as well as postslip osteonecrosis (ON), among the United States pediatric population.
Methods
A national database investigation was performed using PearlDiver Technologies, Inc., queried for SCFE and ON using International Classification of Disease codes (2010 to 2020). Regression analyses to determine the risk of developing a SCFE, and ON after a patient has already been diagnosed with a SCFE (“postslip”). Propensity matching between SCFE and control groups generated a pseudo-randomization model to compare the relative risk.
Results
There were 11,465 patients with SCFE available in the database, matched with 134,680 controls. After matching, vitamin D deficiency, obesity, hypothyroidism, and growth hormone use were risk factors for developing SCFE [relative risk ranges from 1.42 (95% CI: 1.21-1.39, vitamin D deficiency) to 3.45 (95% CI: 3.33-3.57, obesity)]. ON risk factors were vitamin D deficiency [1.65 (1.26-2.14)] and hypothyroidism [1.49 (1.10-2.07)].
Conclusions
This United States national database study quantified risk factors of developing an SCFE and postslip ON. Obesity is the most significant risk factor for the development of a slip, but not ON. Growth hormone use, hypothyroidism, and vitamin D deficiency are also risk factors for SCFE development, whereas only the latter two were associated with ON. These findings demonstrate the public health implications of obesity and comorbid conditions in pediatric hip pathology.
Level of Evidence
Level III.
Recent investigations suggest that physeal morphologic features have a major role in the capital femoral epiphysis stability and slipped capital femoral epiphysis (SCFE) pathology, with a smaller epiphyseal tubercle and larger peripheral cupping of the femoral epiphysis being present in hips with progressive SCFE compared to healthy controls. Yet, little is known on the causal versus remodeling nature of these associations. This study aimed to use preoperative MRIs of patients with unilateral SCFE to perform a comparison of the morphology of the epiphyseal tubercle, metaphyseal fossa, and peripheral cupping in hips with SCFE versus the contralateral uninvolved hips. Pre-operative MRIs from 22 unilateral SCFE patients were used to quantify the morphological features of the epiphyseal tubercle (height, width, and length), metaphyseal fossa (depth, width, and length), and peripheral cupping height in 3D. The quantified anatomical features were compared between hips with SCFE and the contralateral uninvolved side across the whole cohort and within SCFE severity subgroups using paired t-test. We found significantly smaller epiphyseal tubercle heights (P<0.001) across all severities of SCFE when compared to their uninvolved contralateral side. There was a marginally smaller metaphyseal fossa length (P=0.05) in SCFE hips compared to their contralateral uninvolved hips, with mild SCFE hips specifically having smaller fossa and epiphyseal lengths (P<0.05) than their contralateral uninvolved side. There were no side-to-side differences in any other features of the epiphyseal tubercle, metaphyseal fossa and peripheral cupping across all severities (P>0.05). These findings suggest a potential causal role of epiphyseal tubercle in SCFE pathogenesis. This article is protected by copyright. All rights reserved.
Aim: to describe the epidemiology, possible causes and predisposing factors for the development of slipped capital femoral epiphysis. To follow the evolution of classifications. Analyze indications for surgical treatment, as well as types of surgical treatment.
Materials and methods: this review article analyzes the data of Russian and foreign literature on the etiology, pathogenesis, diagnosis and treatment of slipped capital femoral epiphysis.
Results: in view of the frequent distribution in the population, high risks of disability in pediatric patients, the issue of treatment of slipped capital femoral epiphysis remains very relevant. Many methods of surgical treatment have been proposed depending on the stage of the disease, however, they have their own advantages and disadvantages.
Conclusions: Conservative treatment in the long term did not show good results, generally accepted, according to most sources of literature, surgical treatment is considered. The gold standard in the surgical treatment of the disease does not exist today, and the methods and tactics of treatment are being improved.
Slipped capital femoral epiphysis (SCFE) is a diagnosis that should not be missed in pediatric patients, as there is significant morbidity associated with diagnostic delay or inappropriate treatment. While the classic patient is overweight, SCFE is also seen in children with various endocrine disorders. Plain radiography is the initial study of choice, with anteroposterior and frog leg views as required to detect this entity. Ultrasound is emerging as another possible option. Advanced imaging techniques, such as computed tomography and magnetic resonance imaging, are used as adjunct tests by treating subspecialists.
Background
Patients suffered from a slipped capital femoral epiphysis (SCFE) might have beyond their stabilization surgery in the childhood.
Methods
35 patients with SCFE were treated in our clinic and available for a clinical follow-up. The results were compared in dependence of the presence of dysplasia, acetabular retroversion or a FAI type CAM.
Results
A FAI type CAM led to significant inferior results (p < 0.05), especially in combination with a retroversion.
Conclusions
The clinical outcome seemed to be influenced by the presence of a FAI type CAM or a combination with a retroversion, which might aggravate the femoro-acetabular conflict.
Level of evidence
III, retrospective.
Background:
The epiphyseal tubercle, the corresponding metaphyseal fossa, and peripheral cupping are key stabilizers of the femoral head-neck junction. Abnormal development of these features in the setting of supraphysiologic physeal stress under high forces (for example, forces that occur during sports activity) may result in a cam morphology. Although most previous studies on cam-type femoroacetabular impingement (FAI) have mainly focused on overgrowth of the peripheral cupping, little is known about detailed morphologic changes of the epiphyseal and metaphyseal bony surfaces in patients with cam morphology.
Questions/purposes:
(1) Does the CT-based bony morphology of the peripheral epiphyseal cupping differ between patients with a cam-type morphology and asymptomatic controls (individuals who did not have hip pain)? (2) Does the CT-based bony morphology of the epiphyseal tubercle differ between patients with a cam-type morphology and asymptomatic controls? (3) Does the CT-based bony morphology of the metaphyseal fossa differ between patients with a cam-type morphology and asymptomatic controls?
Methods:
After obtaining institutional review board approval for this study, we retrospectively searched our institutional database for patients aged 8 to 15 years with a diagnosis of an idiopathic cam morphology who underwent a preoperative CT evaluation of the affected hip between 2005 and 2018 (n = 152). We excluded 96 patients with unavailable CT scans and 40 patients with prior joint diseases other than cam-type FAI. Our search resulted in 16 patients, including nine males. Six of 16 patients had a diagnosis of bilateral FAI, for whom we randomly selected one side for the analysis. Three-dimensional (3-D) models of the proximal femur were generated to quantify the size of the peripheral cupping (peripheral growth of the epiphysis around the metaphysis), epiphyseal tubercle (a beak-like prominence in the posterosuperior aspect of the epiphysis), and metaphyseal fossa (a groove on the metaphyseal surface corresponding to the epiphyseal tubercle). A general linear model was used to compare the quantified anatomic features between the FAI cohort and 80 asymptomatic hips (aged 8 to 15 years; 50% male) after adjusting for age and sex. A secondary analysis using the Wilcoxon matched-pairs signed rank test was performed to assess side-to-side differences in quantified morphological features in 10 patients with unilateral FAI.
Results:
After adjusting for age and sex, we found that patients with FAI had larger peripheral cupping in the anterior, posterior, superior, and inferior regions than control patients who did not have hip symptoms or radiographic signs of FAI (by 1.3- to 1.7-fold; p < 0.01 for all comparisons). The epiphyseal tubercle height and length were smaller in patients with FAI than in controls (by 0.3- to 0.6-fold; p < 0.02 for all comparisons). There was no difference in tubercle width between the groups. Metaphyseal fossa depth, width, and length were larger in patients with FAI than in controls (by 1.8- to 2.3-fold; p < 0.001 for all comparisons). For patients with unilateral FAI, we saw similar peripheral cupping but smaller epiphyseal tubercle (height and length) along with larger metaphyseal fossa (depth) in the FAI side compared with the uninvolved contralateral side.
Conclusion:
Consistent with prior studies, we observed more peripheral cupping in patients with cam-type FAI than control patients without hip symptoms or radiographic signs of FAI. Interestingly, the epiphyseal tubercle height and length were smaller and the metaphyseal fossa was larger in hips with cam-type FAI, suggesting varying inner bone surface morphology of the growth plate. The docking mechanism between the epiphyseal tubercle and the metaphyseal fossa is important for epiphyseal stability, particularly at early ages when the peripheral cupping is not fully developed. An underdeveloped tubercle and a large fossa could be associated with a reduction in stability, while excessive peripheral cupping growth would be a factor related to improved physeal stability. This is further supported by observed side-to-side differences in tubercle and fossa morphology in patients with unilateral FAI. Further longitudinal studies would be worthwhile to study the causality and compensatory mechanisms related to epiphyseal and metaphyseal bony morphology in pathogenesis cam-type FAI. Such information will lay the foundation for developing imaging biomarkers to predict the risk of FAI or to monitor its progress, which are critical in clinical care planning.
Level of evidence:
Level III, prognostic study.
Musculoskeletal illness represents a significant portion of office visits to primary and urgent care clinicians. Despite this, little emphasis is placed on learning pediatric orthopaedics during medical school or residency. The focus of this paper is to provide a systematic approach to this general musculoskeletal physical exam and to assist in the recognition of what conditions are normal development and what conditions require observation, workup and referral to an experienced pediatric orthopaedist.
Slipped capital femoral epiphysis (SCFE) is a commonly encountered hip disorder. The goal of this study was to describe the incidence of missed contra-lateral SCFE as well as to identify risk factors. The authors hypothesized that contralateral slips are more often missed in patients with severe involvement of the treated side. After institutional review board approval was obtained, a retrospective chart review was performed of all pediatric patients who were treated for sequential and bilateral SCFE at a single institution during an 18-year period. Medical records were reviewed for demographic features and attending surgeon. Radiographs were reviewed for skeletal maturity, Klein's line, and severity of the treated slip. All radiographs were reviewed by 3 pediatric orthopedists. Contralateral SCFE was deemed present when consensus was achieved. Comparisons were made with Fisher's exact test, and P<.05 was considered significant. Of the records that were reviewed, 56 patients met the study criteria. Of these, 19 patients had bilateral involvement and 5 missed slips were identified (8.9%). The patients with missed disease tended to be younger (mean age, 10.8 vs 11.4 years), with a lower body mass index. Fellowship-trained pediatric surgeons were more likely to identify bilateral disease compared with orthopedists without pediatric training (P=.0065). A contralateral slip was more likely to be present in patients who had a positive finding for Klein's line (P<.0001). Severity of the treated slip did not increase the likelihood of missing a contralateral slip. Although Klein's line is a useful tool in the diagnosis of SCFE, a false-negative rate of 40% was observed. The authors recommend increased vigilance when an "atypical" patient with SCFE presents with unilateral disease. [Orthopedics. 2020;43(x):xx-xx.].
Slipped capital femoral epiphysis (SCFE) is a common, surgically treated adolescent hip condition. This study sought to evaluate postoperative complications and factors associated with hospital readmission using a nationally representative database. The 2013 Healthcare Cost and Utilization Project's Nationwide Readmissions Database was queried to analyze the incidence of acute readmission and complications for all patients with SCFE. Patients were separated based on 3 different operative approaches (open procedures, closed procedures, or both) and were compared based on choice of procedure, clinical characteristics, patient demographics, comorbidities, and complications. Univariate and multivariate techniques were used to predict readmission and complications. A total of 1082 patients with SCFE were identified; 58 (5.9%) were readmitted within 90 days of the index surgery, and 47 (73.4%) underwent a "closed" surgery, including 18 bilateral (27.4%). Increasing age and shorter primary length of stay were protective against readmission. Patients with the comorbidity of hypothyroidism were 47.4 times more likely to be readmitted. Obesity, sex, and median household income were not predictive of readmission. Patients readmitted were more likely to have undergone an index procedure of closed reduction or both an open and closed reduction procedure. This study is the first to report national SCFE readmission and complication rates and allows pediatric orthopedic surgeons to have a better understanding of associated risk factors. [Orthopedics. 201x; xx(x):xx-xx.].
Background:
Slipped capital femoral epiphysis (SCFE) and Blount disease are strongly associated with pediatric obesity, yet they have only recently been identified as indications for consideration of metabolic and bariatric surgery (MBS).
Objectives:
To describe the relationships between pediatric obesity, MBS, SCFE, and Blount disease.
Setting:
Nationwide database.
Methods:
The national inpatient sample was used to identify patients ≤20 years old with obesity who underwent MBS from 2007 to 2016. Presence of SCFE and Blount disease was similarly extracted.
Results:
The overall prevalence of SCFE and Blount disease among patients ≤20 years old is .02% for both (14,976, 11,238 patients, respectively) with no statistically significant change over the study period (P = .68, .07, respectively). The rates of SCFE and Blount disease in children with and without obesity are .46% versus .02% and .36% versus .01%, respectively (P < .001 for both). The mean age of patients with SCFE and obesity was 12 years old, while the mean age of those without obesity was 12.2 years old (P = .03). None of the children with obesity and SCFE underwent MBS. Similarly, the mean age of patients with Blount disease and obesity was 12.6 years old, while the mean age of those without obesity was 13.1 years old. Moreover, the mean age of children with Blount disease and obesity who underwent MBS was 16 years old (P < .001).
Conclusions:
Orthopedic complications remain a persistent problem in the pediatric population who suffer from obesity. Despite being diagnosed at a young age, patients with SCFE and/or Blount disease are not undergoing MBS until their later adolescent years, potentially leading to unnecessary disease progression or recurrence of disease after orthopedic interventions. Therefore, SCFE and Blount disease should be considered indications for early consideration of MBS in this pediatric population.
Slipped capital femoral epiphysis (SCFE) is a common paediatric orthopaedic problem that attracts substantive research and debate. The understanding of the pathophysiology of this disorder and its subsequent treatments are evolving at a slow pace. Some forms of treatments have become obsolete while new surgical techniques have emerged which have been widely adopted without substantive evidence regarding long term outcomes. This chapter describes and evaluates the current practice regarding SCFE, the evidence that underpins this practice, in addition to future clinical and research directions.
This study assessed the rate of adverse wound events in individuals with adolescent idiopathic scoliosis who underwent a posterior spinal fusion and sought to determine if obesity was related to the rate of adverse wound events. A retrospective review of patients with adolescent idiopathic scoliosis that underwent posterior spinal fusion between 2001 and 2013 was performed. Preoperative, perioperative, and postoperative data, including wound adverse events, were obtained through medical record review. Using the Center for Disease Control BMI criteria, participants were grouped into overweight/obese (BMI%≥85 percentile) or healthy/underweight (BMI%<85 percentile) groups. Obesity and prolonged hospital stay were independent risk factors for increased risk of wound problems.
Objective:
To prospectively characterize pain locations in slipped capital femoral epiphysis (SCFE) and evaluate pain locations as predictors of a delay in diagnosis.
Study design:
This was an institutional review board approved prospective study of 110 children who underwent surgery for SCFE at a tertiary children's hospital between 2009 and 2015. Standardized pain diagrams were completed by 107 children. Pain zones were designated via a composite diagram. Hips without hip pain were categorized as atypical; hips with hip pain were typical.
Results:
In total, 122 hips were eligible for pain zone analysis. Seventy hips (57.4%) had hip pain. Atypical pain was present in 52 hips (42.6%), which included groin pain in 17 hips (13.9%), thigh/leg pain in 43 (35.2%), knee pain in 32 (26.2%), and posterolateral pain of the hip and leg in 13 (10.7%). A combination of pain zones was present in 48 hips (39.3%). Forty-nine percent of patients had more than 1 visit until diagnosis. The three most common pain locations for typical hips were hip, hip/thigh, and hip/knee pain (77.2% of typical hips). The 3 most common pain locations for atypical hips were isolated thigh, knee, and groin (65.4% of atypical hips). The least common pain presentations had a longer duration of symptoms (P = .04) and more healthcare visits before diagnosis (P = .04).
Conclusions:
A combination of pain locations is common in SCFE. Less frequent pain presentations may delay diagnosis. Delays in diagnosis continue despite education efforts.
This report presents the revised growth charts for the United States. It summarizes the history of the 1977 National Center for Health Statistics (NCHS) growth charts, reasons for the revision, data sources and statistical procedures used, and major features of the revised charts.
Data from five national health examination surveys collected from 1963 to 1994 and five supplementary data sources were combined to establish an analytic growth chart data set. A variety of statistical procedures were used to produce smoothed percentile curves for infants (from birth to 36 months) and older children (from 2 to 20 years), using a two-stage approach. Initial curve smoothing for selected major percentiles was accomplished with various parametric and nonparametric procedures. In the second stage, a normalization procedure was used to generate z-scores that closely match the smoothed percentile curves.
The 14 NCHS growth charts were revised and new body mass index-for-age (BMI-for-age) charts were created for boys and girls (http://www.cdc.gov/growthcharts). The growth percentile curves for infants and children are based primarily on national survey data. Use of national data ensures a smooth transition from the charts for infants to those for older children. These data better represent the racial/ethnic diversity and the size and growth patterns of combined breast- and formula-fed infants in the United States. New features include addition of the 3rd and 97th percentiles for all charts and extension of all charts for children and adolescents to age 20 years.
Created with improved data and statistical curve smoothing procedures, the United States growth charts represent an enhanced instrument to evaluate the size and growth of infants and children.
The dramatic increase in the prevalence of childhood overweight and its resultant comorbidities are associated with significant health and financial burdens, warranting strong and comprehensive prevention efforts. This statement proposes strategies for early identification of excessive weight gain by using body mass index, for dietary and physical activity interventions during health supervision encounters, and for advocacy and research.
To test the hypothesis that in a healthy pediatric population body mass index (BMI) (kilograms per meter square) is a valid measure of fatness that is independent of age for both sexes.
Total body fat (TBF) (in kilograms) and percent of body weight as fat (PBF) were estimated by dual energy x-ray absorptiometry (DXA) in 198 healthy Italian children and adolescents between 5 and 19 years of age. We developed multiple regression analysis models with TBF and percent body fat as dependent variables and BMI, age, and interaction terms as independent variables. Separate analyses were conducted for boys and girls.
BMI was strongly associated with TBF (R2 = 0.85 and 0.89 for boys and girls, respectively) and PBF (R2 =0.63 and 0.69 for boys and girls, respectively). Confidence limits on BMI-fatness association were wide, with individuals of similar BMI showing large differences in TBF and in PBF. Age was a significant covariate in all regression models. Addition of nonlinear terms for BMI did not substantially increase the R2 for TBF and PBF models in boys and girls.
Our results support the use of BMI as a fatness measure in groups of children and adolescents, although interpretation should be cautious when comparing BMI across groups that differ in age or when predicting a specific individual's TBF or PBF.
One thousand six hundred thirty children with 1993 slipped capital femoral epiphyses were reviewed; 41.2% were girls and 58.8% were boys. There were 47.5% white, 24.8% black, 16.9% Amerindian, 7.4% Indonesian-Malay, 2.1% Native Australian/Pacific Islands, and 1.3% Indo-Mediterranean children. The diseased hip was unilateral in 77.7% and bilateral in 22.3% of the children, and chronic in 85.5% and acute in 14.5% of the children. Of the unilateral slips, 40.3% involved the right hip and 59.7% the left hip. The child's weight was greater than or equal to the ninetieth percentile in 63.2% of the children. The average age for the girls and boys was 12 and 13.5 years. The age at diagnosis decreased with increasing obesity. The youngest children were the Native Australian/Pacific Island children (11.8 years) and the oldest were the white and Indo-Mediterranean children (13 years). The Indonesian-Malay and Indo-Mediterranean children were the lightest in weight, and the black children the heaviest. The Indo-Mediterranean children had the highest proportion of boys (90.5%), and the Native Australian/Pacific Island children the lowest (50%). The highest percentage of bilaterality was in the Native Australian/Pacific Island children (38.2%), and the lowest in the Amerindian children (16.5%). The relative racial frequency of slipped capital femoral epiphysis compared with the white population was 4.5 for the Polynesian, 2.2 for the black, 1.05 for the Amerindian, 0.5 for the Indonesian-Malay, and 0.1 for the Indo-Mediterranean children. In children with unilateral involvement, the age at presentation was younger for those children in whom bilateral disease later developed (12 versus 12.9 years old). In 82% of the children with sequential bilateral slips, the second slip was diagnosed within 18 months of the first slip.
To evaluate whether body mass index (BMI) is a representative equivalent measure of body fatness independent of age, race, gender, sexual maturation, and distribution of fat in children and adolescents.
Cross-sectional study of 192 healthy subjects (100 boys and 92 girls, 103 white and 89 black) age 7 to 17 years. Methods. Height and weight were measured in the standard fashion, and BMI (kg/m) was calculated from these values. Fat mass and percent body fat were determined using dual-energy x-ray absorptiometry. Sexual maturation was evaluated by physical assessment. Distribution of fat was determined by the waist:hip ratio.
There were no significant differences by gender and ethnic group for any of the demographic or anthropometric variables, except waist:hip ratio, which was higher in white compared with black boys. BMI was significantly and positively correlated with age, stage of maturation, and all of the anthropometric variables in each race-sex group. The correlation of maturation stage with BMI was stronger than the correlation between age and BMI. A multiple regression analysis showed that BMI, gender, race, sexual maturation, and distribution of fat were all significant independent correlates of the percent body fat (multiple R = .77). The percent body fat-BMI relationship was dependent on the stage of sexual maturation, gender (for an equivalent BMI, girls have greater amounts of body fat than boys), race (for equivalent BMI, whites have higher body fat than blacks), and waist:hip ratio (for equivalent BMI, those with central obesity have greater body fatness than those with peripheral obesity).
BMI is not an equivalent measure of the percent body fat for each race-sex group. When BMI is used as a measure of body fatness in a research or clinical setting, particularly when comparisons are made across race and gender, it may be important to consider the maturation stage, race, gender, and distribution of body fat in the interpretation of the results.
The prevalence of children and adolescents with body mass index (BMI) of greater than 95th percentile has doubled in the last 2 decades (present prevalence is 10.9%) and there is a 50% increase in the prevalence of those with a BMI greater than 85th percentile (present prevalence is 22.0%) in the US. There are substantial risks for morbidity in obese children even before they reach adulthood. Further, if obesity in childhood persists into the adult years, the morbidity and mortality is greater than if the obesity developed in the adult. Screening using appropriate historical and physical data will reveal those children most in need of modification of weight gain.
Body mass index (BMI) as a predictor of slipped capital femoral epiphysis (SCFE) was studied. A total of 26 adolescent patients had complete annual height and weight measurements taken from birth to onset of slippage. These values were compared with those of the normal adolescent population. Patients with SCFE showed statistically higher BMI during growth than normal developing children. BMI gives more accurate data on body build than height and weight alone and may be a useful tool for evaluating risk factors in SCFE.