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ORIGINAL ARTICLES

Proximal femoral epiphysiolysis

D. Bertrand-lvarez, J. Pena Vzquez, A. Sols Gmez, I. Fernndez-Bances, S. lvarez-Parrondo,
P. Lpez Fernndez and J. Paz-Jimnez
Orthopedics and Trauma Surgery Department I., Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain.

Purpose. Hip epiphysiolysis of unknown origin is frequent

in children and adolescents. It is a point of controversy
whether the orthopedic surgeon should act to correct this
disorder. We reviewed 108 cases in 94 patients operated
on in our Department from 1976 to 2002 and analyzed the
results.
Materials and methods. In most cases treatment consisted
of in situ reduction and osteosynthesis with K-wires, and
cannulated or cancellous screws.
Results. 67% of the patients were male with an average age
at diagnosis of 13.25 years; 33% of the patients were female
with an average age at diagnosis of 12.27; 14.9% of the patients were bilateral cases (14 patients). We had good results in 81% of the acute cases, in 73% of the acute on
chronic cases and in 89% of the chronic cases.
Discussion and conclusions. More aggressive surgical
techniques such as neck or transtrochanteric osteotomies
do not seem to excessively modify the poor results of epiphysiolysis with severe uncorrected displacement. Poor results were seen in the group of epiphysiolysis cases with
severe initial slip or in those cases which developed chondrolysis or non-septic necrosis of the femur head. The fixation technique requires great skill; the osteosynthesis materials must not penetrate the intra-articular space; the
procedure must not cause a valgus deformity. Currently,
osteosynthesis using a single cannulated screw is the preferred procedure.

Epifisiolisis femoral proximal

Key words: proximal femoral epiphysiolisis, hip, treatment.

Palabras clave: epifisiolisis femoral proximal, cadera,

tratamiento.

Proximal femoral epiphysiolysis (PFE) is one of the

most frequent pathologic disorders in adolescent hips

and, even nowadays, a cause of hip osteoarthritis. A

greater incidence is seen in overweight children1-5.
Ambroise Par, in 1572, was the first to describe this
disorder. In the nineteenth century it was also recognized
by Hoffmeister (1884), Kocher (1885), Ernst Mller
(1888) and Strengel (1898)1. It has received many different names through the ages: coxa vara, bending of the
neck of the femur, coxa retorsa.
Though also currently known as adolescent coxa

Address correspondence to:

D. Bertrand-lvarez
Avda Pedro Masaveu 1, 5A
33007 Oviedo (Asturias) SPAIN
email: dbertrandalvarez@yahoo.es
Received: March 2004.
Accepted: February 2005.

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Objetivo. La epifisiolisis de cadera es una entidad frecuente en

el nio o adolescente, de etiopatogenia desconocida. La actuacin del cirujano ortopdico para detener y corregir esta enfermedad es un tema controvertido. Se realiza una revisin de
108 casos intervenidos en nuestro Servicio en 94 pacientes entre los aos 1976 y 2002, analizando los resultados obtenidos.
Material y mtodo. El tratamiento consisti en la mayora
de los casos en reduccin y osteosntesis in situ con agujas
de Kirschner, tornillos de esponjosa o tornilllos canulados.
Resultados. El 67% eran varones con una edad media al diagnstico de 13,25 aos; el 33% mujeres, con una media de
12,27 aos. En 14 casos la afectacin era bilateral (14,9%).
Se obtuvieron buenos resultados en el 81% de los casos de
epifisiolisis aguda, en el 73% de las agudas sobre crnicas y
en el 89% de las crnicas.
Discusin y conclusiones. Las tcnicas quirrgicas ms
agresivas, como osteotomas cervicales o transtrocantreas,
no parecen modificar en exceso el mal resultado de epifisiolisis con desplazamiento severo no corregido. Aquellos
casos en los que se obtuvieron malos resultados pertenecan
al grupo de epifisiolisis con desplazamiento inicial severo, o
a aquellos en los que se desarroll una necrosis asptica de
la cabeza femoral o una condrlisis. Se considera de gran
importancia la exquisitez a la hora de realizar la fijacin,
evitando la penetracin intraarticular del material y su colocacin en valgo. Actualmente se prefiere la osteosntesis
con un solo tornillo canulado.

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Bertrand-lvarez D, et al. Proximal femoral epiphysiolysis

vara, it would seem that the correct name for this condition is proximal or upper femoral epiphysiolysis, or hip
epiphysiolysis6. In this disorder the neck of the femur is
displaced forwards and upwards in relation to the proximal epiphysis, which remains normally positioned with
respect to the acetabulum3,7,8. Though multiple factors
have been blamed, to a greater or lesser degree, the causes which give rise to this slip are not yet clear. It has always been considered that the probable origin is multifactorial, though theories that propose hormonal and
mechanical causes are the most popular4,8,12.
If the slip is not treated it frequently stabilizes, the
epiphysiolysis heals and causes deformities. Currently,
there is much debate as to what the orthopedic surgeon
should do to stop and correct the development of this
condition, specially in those cases in which there is a risk
of complications, as these can be more severe than the
natural history of the disease itself, if there is instability
of the proximal union between the epiphysis and metaphysis of the femur, or if there is a severe slip1,13,14.
In this study we analyze our experience of the management of this disorder, and the results and complications seen during treatment.

MATERIALS AND METHODS

We carried out a retrospective study of 108 cases of

proximal femoral epiphysiolysis in 94 patients treated
surgically in our Department from 1976 to 2002. Inclusion criteria for this review were: only surgically treated
cases, follow-up longer than 1 _ years, and adequate
clinical and radiographic documentation to assess evolution. We excluded those patients in which surgical treatment was not advisable either due to a concomitant clinical condition or due to the severity of associated disease.
These patients received orthopedic treatment (7 patients).
A questionnaire was drawn up to determine sex, age
of onset, age at surgery, associated familial conditions,
side affected, bilateral disease, etc. The X-rays and clinical histories of all patients were reviewed and the patients who could be recalled underwent a physical exam.
We used a frequently applied classification that is
based on the duration of symptoms from time of onset of
disease1.
1) Acute epiphysiolysis is defined as an epiphyseal
slip in a patient with less than 3 weeks symptoms and
an X-ray with no sign of remodeling in the metaphyseal
region of the femur neck.

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Figure 1. Helicoidal axial tomography image of a proximal femoral

epiphysiolysis with severe slip.

2) Acute on chronic slip is the condition in which the

symptoms are also of less than 3 weeks duration, but
there are radiological signs of remodeling of the metaphysis.
These would both be unstable epiphysiolysis.
3) Stable epiphysiolysis or chronic slip is a condition
of more than 3 weeks duration, with remodeling. Stable
epiphysiolysis too can be classified according to the
head-shaft angle seen in axial radiographic views. According to the degree of head-neck slip: mild displacement would be an angle of less than 30, moderate between 30 and 60, and severe more than 60 (Figure 1).
The type and severity of the slip, and the duration of
the symptoms were the criteria for the choice of treatment. This algorithm is graphically illustrated in Figure
2 and Figure 3. In cases of acute on chronic PFE the
same criteria were used as in acute PFE.
Results have been assessed using clinical, subjective
and Dunn and Angels radiographic criteria 5, modified

Acute epiphysiolysis

Mild

In situ
fixation

Moderate

Severe

Reduction
attempt

Reduction
attempt

In situ
fixation

Intracapsular
cervical osteotomy

Figure 2. Algorithm for the management of acute epiphysiolysis.

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Bertrand-lvarez D, et al. Proximal femoral epiphysiolysis

Table 2. Outcomes according to form of onset.
Chronic epiphysiolysis

Severe

Moderate

Mild

< 45

Type of
Epiphysiolisis

N. of
cases

Good
outcome

Fair
outcome

Poor
outcome

Acute
Acute/Chronic
Chronic

27
15
66

22 (81%)
11 (73%)
59 (89%)

3 (11%)
3 (20%)
3 (4,5%

2 (7,4%)
1 (6,6%)
4 (6%)

> 45

Table 3. Outcomes according to degree of initial slip

Reduction
attempt

Degree
of slip
In situ
fixation

In situ
fixation

In situ
fixation

Trochanteric
osteotomy

Slight
Moderate
Severe

N. of
cases

Good
outcome

67 (62%) 64 (95,5%)
28 (26%) 24 (85,7%)
15 (14%) 7 (46,6%)

Fair
outcome

Poor
outcome

2 (3%)
2 (7%)
4 (26,6%)

1 (1,5%)
2 (7%)
4 (26,6%)

Figure 3. Algorithm for the management of chronic epiphysiolysis.

by the authors (Table 1). The overall result was considered good if the sum of points totaled 5 or 6; fair: 3 or 4
points; poor: 0.1 to 2 points. These results depend on
condition at presentation and the degree of slip, as can be
seen in Table 2 and Table 3.
Head-shaft angle and complications during treatment
were assessed
during the postoperative period and on review in the
midterm follow-up.

RESULTS

Characteristics of the patient population: 63 of the 94

patients (67%) were male with an average age at diagnosis of 13.25 years; 31 patients (33%) were female with
Table 1. Dunn and Angel outcome classification system
Good
Subjetive

Clinical

Radiologica

2: Asymptomatic 1: Ocasional
pain
Normal
function
2: Normal
1: Flexion 90
function and No
mobility
permanent
2: Good
1: Varus
reduction
deformity
Head with
good contour
Normal
articular
contour
Normal bone
texture

Modificada de Dunn DM et al15.

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Fair

Poor
0: Regular pain
Some functional
limitations Some
second surgeries
0: Flexion < 90.
Permanent
Deformity
0: Articular
impingement
Irregular
head
contour
Bone cysts
Changes in
bone density

an average age at diagnosis of 12.27. In both sexes the

age ranged from 10 to 17. In 30 cases (32%) the right hip
was affected and in 50 cases (53.2%) the left; 14 cases
(14.9%) were bilateral.
The average follow up was 14 years (minimum 1.5
and maximum 26).
Body type morphology was normal in 33 cases (35%),
obese in 54 cases (47.4%) and asthenic in 7 cases (7.4%).
As to association with other diseases, we only saw 2
cases of obese patients in which, by means of appropriate
diagnostic tests, adiposogenital syndrome was detected.
No associations were found with hypothyroidism, hormonal treatment or kidney disease. In our series, we only
saw familial association in 1 case of identical twin sisters.
We were unable to estimate the incidence of this disease since the population seen in our Department
changed during the study period and we have no reliable
statistical data on this variation.
According to presentation of the condition: 27 cases
were acute (25%), 66 chronic (61%) and 15 cases were
acute on chronic (13.8%).
According to displacement measured in degrees of
Southwicks head-shaft angle: 67 cases were mild (62%),
28 were moderate (26%) and 13 were severe (12%).
As to clinical characteristics we must point out that
all patients suffered pain and lameness, though in their
records it was not clear which symptom was first, or if
they appeared simultaneously. There was a previous history of trauma in 23% of the patients.
All patients were operated on after a 24 hour to 14
day period (average 7.7 days) of bed rest with traction of
soft tissues.
In 100 cases (92.6%), after an attempt to achieve
closed reduction under radiographic control, the technique used was in situ fixation of the epiphysis using

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Bertrand-lvarez D, et al. Proximal femoral epiphysiolysis

Figure 4. Cannulated screws in right hip and K- wires in left hip in

proximal femoral epiphysiolysis.

moderate traction on an orthopedic table and slight internal rotation, followed by fixation with K-wires and cancellous or cannulated ASNIS type screws (Figure 4). The
technique chosen varied according to the surgeons preference and experience, and the type and degree of slip.
As regards the other 8 cases (7.4%), we considered that a
cuneiform cervical osteotomy or Dunn procedure was
necessary in 3 patients (2.7%) and a transtrochanteric
three-dimensional osteotomy or Inhuser procedure in 5
patients (4.6%).
In cases of in situ fixation, the most frequently used
method was fixation with ASNIS cannulated screws in
42 cases (39%), only 1 screw was used in 70% of these
and 2 screws were used in 30%. In 37 cases (34%) Kwires were used with an average of 3.4 wires per case
(minimum 3, maximum 5). Cancellous screws were used
in 29 cases (26.8%); only 1 screw was used in 55.3% of
these and 2 screws were used in 44.7%.
Patients were allowed to walk with partial weight
bearing from the eighth week onwards.
The orthopedic material was removed, on average, at
16.75 months (range 7-30 months).
Amongst the preoperative complications we had:
Five cases of superficial infection of the surgical
wound (4.6%), which were treated locally and with intravenous antibiotics, the most frequent pathogen was S.
aureus.
Four cases of breakage of Kirschner wires (3.7%)
during surgery.
Two cases of screws becoming detached from
their heads, which made their extraction impossible as
the threaded portion remained trapped in the physis
when it closed (Figure 5).
Two cases of paresis of the external popliteal
nerve of unknown origin, with total recovery after a
year.
One case of muscular hernia which did not require
re-intervention.

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Figure 5. Perioperative complication: broken screw head which will

considerably complicate the final extraction of the screw.

One case of deep vein thrombosis during the immediate postoperative period which was successfully
treated by conventional means.
One case of breakage of the bit in which the distal
fragment remained within the bone.
Nine cases (8.3%) in which it was found, during
the postoperative period, that osteosynthesis material had
penetrated the joint (Figure 6).
As to articular movement, six cases showed limitation of internal rotation and a certain degree of pain; two
of these patients suffered avascular necrosis and the other four patients had undergone an intertrochanteric osteotomy. Two patients limped and one of them also presented with genus valgus and a 1.5 cm dissymmetry.
One of these patients was operated using the Dunn technique and the other underwent external manipulation and
epiphysiodesis with screws. Both evolved to avascular
necrosis.
Late complications such as nonseptic necrosis of the

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Bertrand-lvarez D, et al. Proximal femoral epiphysiolysis

Figure 6. Kirschner wire penetrating intra-articular space during

surgery.

Figure 7. X-ray of chondrolysis five years after surgery.

femur head (NSNFH) and chondrolysis can be seen in

Table 4.
Non-septic necrosis of the femur head (NSNFH) was
seen in 3 cases. Two cases were acute PFEs, with severe
displacement: one was treated by means of in situ reduction and fixation, the other underwent a Dunn osteotomy.
One case was an acute on chronic PFE with severe displacement in which in situ reduction and fixation was
carried out.
There were 4 cases of chondrolysis (Figure 7), all
seen in chronic PFEs with variable degrees of displace-

ment. Two of these were cases in which it was seen that

osteosynthesis material had penetrated the joint.
Of the 28 cases which presented with severe displacement, the average initial head-shaft angle was 71.
After surgery this angle was corrected to an average of
29. In the radiographic exam carried out after 46.5
months a new correction caused by remodeling was seen
with a further decrease of the angle to an average of 18.
Good results were seen in only 2 of those patients for
whom, due to the size of their displacement, a re-orientating
osteotomy was considered appropriate. The results were fair
or poor in the remaining 6. No non-unions were seen.

Table 4. Late complications at femoral head level according

to degree of slip

Acute
Acute/Chronic
Chronic

Chondrolysis

FHAN

0
0
4

2
1
0

FHAN: Femoral head avascular necrosis.

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DISCUSSION

There is an ongoing debate as to the treatment of

choice for PFE according to the phase and degree of
severity of the disease. Different methods have been
used for in situ fixation: Kirschner wires, cannulated
screws, Steinman screws, cancellous screws, etc

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Bertrand-lvarez D, et al. Proximal femoral epiphysiolysis

The most widely accepted treatment for stable PFE

is in situ fixation with one or more central screws. In
cases of acute epiphysiolysis we always attempt reduction on a traction table first. This manoeuvre must be
gentle and progressive. On the contrary, in cases of
chronic epiphysiolysis no such attempts are made.
Kirschner wires are less aggressive for the physis,
but a greater number must be placed to obtain an appropriate degree of stability.
When fixation is done with cancellous screws in
younger adolescents - we only use screws with an extremely short thread (15 mm) - an epiphysiodesis may
result, with the corresponding dissymmetry. This technique does not cause excessive dissymmetry. In older
adolescents whose physis are near closure - it must be remembered that the physis is responsible for 30% of the
growth in length of the femur2 - the use of this technique
does not cause excessive disymmetries.
When the displacement is severe there are alterations
of the growth plate and a greater amount of osteosynthesis material may be used to ensure fixation, since in
these cases the physis does not have such a great growth
potential.
Currently, most of the discussion on the management
of this condition focuses on which is the best treatment
in cases of severe displacement. An all-out attempt to
reestablish the neck-shaft congruence can cause severe
complications in the hip since it may markedly affect the
precarious blood supply to the femur head1,16,17.
There is much controversy as to the best treatment
for unstable epiphysiolysis. Usually corrective osteotomies are only carried out in patients who have
stopped growing and present with severe deformities.
A meticulous fixation technique is of prime importance when carrying out a fixation with osteosynthesis
material. This material must not penetrate the intra-articular space nor must it be placed in valgus within the
neck of the femur, since the upper posterior part of the
femur head is the region where the probability of causing
vascular damage is greatest18,20.
No relation was found between the type of ostesynthesis material used and rate of intra-articular penetration.
Careful knowledge of the surgical technique and the
special anatomic characteristics of the adolescent hip are
necessary.
To minimize the percentage of complications, we believe that the least possible amount of osteosynthesis material should be used. In most cases, but most specially in
chronic cases, fixation using just one screw is sufficient
to achieve appropriate stability5,20,21. This can, on occasion , cause complications, such as screw breakage, specially in very obese patients, where one screw may not
be able to withstand rotational and shear forces. For this

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reason, some authors continue to recommend the use of

two screws22.
More aggressive surgical techniques such as cervical
and transtrochanteric osteotomies do not seem to excessively modify the poor results in non-corrected PFEs
with severe slip, specially in view of the apparent tendency toward remodeling of the head-neck junction23.
We wish to underline that those cases with poor outcomes belonged in the group of PFEs with severe initial
slip that developed femoral head avascular necrosis or
laminar chondrolysis.
To be able to treat PFE appropriately with satisfactory
results in the long term, early detection is of vital importance, specially in those cases where the slip is gradual.
The most important factor for an early detection of
this condition is to remember that it exists and, at the
slightest clinical suspicion, always be certain to rule it
out during diagnosis.

REFERENCES
1. Gasco J, Sangesa MJ, Castejn M. Epifisiolisis de cadera.
Rev Esp Cir Osteoart. 1994;29:93-110.
2. Vzquez Surez G, lvarez Garca JC, Gutirrez Granda ME,
Lpez Fernndez P, Fernndez Moral V. Epifisiolisis capitis
femoris. Rev Esp Cir Osteoart. 1989;24:349-64.
3. Loder RT, Richards BS, Shapiro PS, Reznick LR, Aronson
DD. Acute slipped capital femoral epiphysis: the importance of
phiseal stability. J Bone Joint Surg Am. 1993; 75A:1134-40.
4. Tachdjian MO. Deslizamiento de la epfisis de la cabeza del
fmur. En: Tachdjian MO, editor. Ortopedia Peditrica. Mxico DF: Nueva editorial Interamericana SA; 1994. p.1097-167.
5. Canale ST. Fracturas y luxaciones en la infancia. En: Canale
ST, editor. Campbell. Ciruga Ortopdica. 9 ed en espaol.
Tomo III. Madrid: Harcourt; 1998. p.2363-537.
6. Gmez Navaln LA, Marn Morales LA, Muoz Berenguer
JA, Salido Valle JA. Nuestra experiencia en el tratamiento de
la epifisiolisis femoral proximal. Algunos aspectos controvertidos. Rev Ortop Traumatol. 2000;44:294-8.
7. Aronsson DD, Loder RT. Treatment of Unstable Acute
Slipped Capital Femoral Epiphysis. Clin Orthop. 1996;322:
99-110.
8. Lorente R, Casado JM, Fuster R, Gala M. Consideraciones
etiopatognicas en el tratamiento de la epifisiolisis femoral
superior. Rev Ortop Traumatol. 1988;32:377-81.
9. Mirkopulos N, Weiner DS, Askew M. The evolving slope of
the proximal femoral growth plate relationship to slipped capital femoral epiphysis. J Pediatr Orthop. 1988;8:268-73.
10. Pritchett JW, Perdue KD. Mechanical factors in slipped capital femoral epiphysis. J Pediatr Orthop. 1988;8:385-8.
11. Givn U, Bowen JR. Chronic slipped capital femoral epiphysis: Treatment by pinning in situ. J Pediatr Orthop. 1999;8:
216-22.
12. Xicoy J, Surroca M. La epifisiolisis de la cadera en su
relacin con la obesidad del adolescente. Rev Ortop Traumatol. 1982;26:613-22.
13. Carney BT, Weinstein SL, Noble J. Long-term follow-up of
slipped capital femoral epiphysis. J Bone Joint Surg Am.
1991;73A:667-74.

Rev Ortop Traumatol. 2005;49:334-40

339

Documento descargado de http://zl.elsevier.es el 09/11/2014. Copia para uso personal, se prohbe la transmisin de este documento por cualquier medio o formato.

Bertrand-lvarez D, et al. Proximal femoral epiphysiolysis

14. Kallio PE, Lequesne GW, Paterson DC, Foster BK, Jones JR.
Ultrasonography in slipped capital femoral epiphysis. J Bone
Joint Surg Br. 1991;73B:884-9.
15. Dunn DM, Angel JC. Replacement of the femoral head by
open operation in severe adolescent slipping of the upper
femoral epiphysis. J Bone Joint Surg Br. 1978;60B:394-403.
16. Rey JC, Carlioz H. Epiphysiolises a grand deplacement. Reduction sanglante par le technique de Dunn. Rev Chir Orthop.
1975;61:261-73.
17. Vrettos BC, Hoffman EB. Chondrolysis in slipped upper
femoral epiphysis. Long-term study of the aetiology and natural history. J Bone Joint Surg Br. 1993;75B:956-61.
18. Bellemans J, Fabry G, Molenaers G, Lammens J, Moens P.
Pin removal after in-situ pinning for slipped capital femoral
epiphisis. Acta Orthop Belg. 1994;60:170-2.
19. Gonzlez Morn G, Carsi B, Abril JC, Albiana J. Results after preoperative traction and pinning in slipped capital
femoral epiphysis: K Wires versus cannulated screws. J Pediatr Orthop. 1998;7:53-8.
20. Ward WT, Stefko J, Wood KB, Staniski CL. Fixation with a
single screw for slipped femoral capital epiphysis. J Bone
Joint Surg Am. 1992;74A:799-809.

340

21. Riley PM, Weiner DS, Gillespie R, Weiner SD. Hazards of

internal fixation in the treatment of slipped capital femoral
epiphysis. J Bone Joint Surg Am. 1990;72A:1500-9.
22. Gmez Canedo JM, Troncoso Durn J, Rueda Crespo D, Larrauri Puebla P. Epifisiolisis femoral proximal. Rev Ortop
Traumatol. 1993;37:154-9.
23. Clarke NM, Harrison MH. Slipped upper femoral epiphysis.
A potential for spontaneous recovery. J Bone Joint Surg Br.
1986;68B:541-4.

Conflict of interests: We, the authors, have not received any economic support to carry out this study.
Nor have we signed any agreement with any commercial firm to receive benefits or fees. On the other hand,
no commercial firm has provided nor will provide
economic support to non-profit foundations, educational institutions or any of the other organizations
that we are members of.

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