Arch Orthop Trauma Surg (1989) 108 : 336-338
ndTrauma Surgery
Acute-on-Chronic Bilateral Reversed Slipped Capital Femoral
Epiphysis Managed by Imhauser-Weber Osteotomy
M. A. Scher, M. B. E. Sweet, and I. Jakim
Department of Orthopaedic Surgery and MRC Bone and Joint Research Unit, University of the Witwatersrand, Johannesburg,
South Africa
Summary. I n a rare case of progressive bilateral valgus-
slipped capital femoral epiphysis, modified Imhauser-
W e b e r o s t e o t o m i e s w e r e c a r r i e d out. T h e o s t e o t o m i e s
a l l o w e d for s i g n i f i c a n t v a r u s c o r r e c t i o n a n d t h u s in-
c l u d e d s h o r t e n i n g o f t h e n e c k a n d distal t r a n s f e r of
the greater trochanter. The planning technique of the
c o m p l e x o s t e o t o m y is d i s c u s s e d . A t 5 - y e a r f o l l o w - u p
the patient had a gratifying result.
Reversed or valgus-slipped capital femoral epiphysis
is v e r y r a r e . O f t h e 12 cases r e p o r t e d i n t h e l i t e r a t u r e
[ 1 - 5 , 9, 11], to o u r k n o w l e d g e o n l y t h r e e w e r e b i l a t -
e r a l [3, 5]. W e r e p o r t a c a s e o f a c u t e - o n - c h r o n i c re-
v e r s e d b i l a t e r a l slip ( v a l g u s a n d p o s t e r i o r ) o f t h e cap-
ital f e m o r a l epiphysis i n which it was c o n s i d e r e d neces-
sary to p e r f o r m b i l a t e r a l m o d i f i e d I m h a u s e r - W e b e r
o s t e o t o m y [6].
Case Report
A 14-year-old girl was referred with a history of spontaneous
onset of increasing bilateral hip pai n of one year's duration;
this had forced her to give up all physical activities. The left
side was worse than the right. She had a left-sided limp and re-
duced walking ability (500 metres) and she experienced diffi-
culty in sitting on a low chair. The patient's past medical and
family history was noncontributory. Examination showed the
patient to be postpubertal; her height was 172cm, her weight
56 kg. General physical examination revealed no abnormalities.
Specifically, there was no abnormal ligamentous laxity. She
walked with a bilateral antalgic limp combined with a left-sided
Trendelenburg lurch. There was no rotational deformity in the
lower limbs.
Flexion was to 90 ~ on the left and 100~ on the right. There
was bilateral hyperextension, 40~ on the left and 25~ on the
right. Other movements were within normal limits. Pain was
particularly marked at the extremes of motion on both sides.
Clinically, the legs were of equal length. Other than abductor
weakness on the left, muscle power was within normal limits.
Offprint requests to: M.A. Scher, P.O.Box 91285, Auckland
Park 2006, South Africa
Ahves~Orthopaedic
9 Springer-Verlag 1989
Anteroposterior radiographs of the pelvis with the hips in
identical degrees of rotation had been taken 9 months before
referral: there was an exaggerated neck shaft angle of 168~
the right and of 170~ on the left. The growth plate was horizon-
tal on the right and tilted into mild valgus on the left. The ace-
tabular indices were normal. The capital epiphyses were sub-
luxed laterally - more so on the left, due to valgus tilt (Fig. 1).
Similar radiographs taken on presentation 9 months later
(Fig. 2) revealed further valgus slip of the capital epiphyses and
loss of coverage bilaterally. The growth plates were still open
and displayed increased valgus tilt with evidence of lateral com-
pressive changes. Lateral views demonstrated posterior slip of
the capital epiphyses measuring 25~ on the right and 30~ on the
left (Fig. 3). There was no evidence of any endocrinological ab-
normality.
The osteotomies were planned from biplanar tracings of
the radiographs, modifying the Imhauser-Weber technique to
allow correction of posterolateral slip (Fig. 4). The maximum
direction of slip was valgus, the posterior component being of
moderate degree. Thus the osteotomies were calculated to give
45~ of varus and 25 ~ of flexion on the left and 35~ of varus and
20~ of flexion on the right. In view of the magnitude of varus
correction, provision was made for shortening of the neck and
distal transfer of the greater trochanter.
Intertrochanteric osteotomies were carried out 4 months
apart, starting with the right hip. The capsule was opened and
the epiphysis was transfixed with a cancellous AO screw. The
osteotomy was carried out as planned and achieved the desired
correction. Rotational correction was assessed intraoperatively.
The osteotomy was stabilized with an adolescent-type 90~ A O
blade plate. The patient's initial postoperative course was une-
ventful. She was mobilized with touch weight bearing on crutches
a few days after surgery and discharged on the sixth postopera-
tive day. When healing of the osteotomy was considered ade-
quate the second procedure was carried out as before. The
early postoperative course was uneventful. However, her sub-
sequent compliance regarding restriction of weight bearing was
poor, resulting in implant failure with loss of position at the
osteotomy site on the left. Six months postoperatively the left
osteotomy was repeated and fixation achieved with an adult
A O 130~ blade plate.
Serial radiographs over the ensuing 12 months demonstrated
the development of mild flattening of the left femoral head with
a small underlying, cranially positioned avascular segment and
slight narrowing of the superior joint space.
The patient has been followed up annually for 5 years. She
has remained asymptomatic and returned to sporting activities
M. A. Scher et al. : Bilateral Reversed Slipped Capital Femoral Epiphysis
Fig. 1. Anteroposterior view of the pelvis, showing both hips 9
months before presentation. The exaggerated neck-shaft
angle and early reversed slipped femoral capital epiphysis are
evident
Fig. 2. Anteroposterior view of the pelvis at age 14 years.
Progressive lateral slip of the capital femoral epiphysis has
occurred. There is valgus tilt of the growth plate and uncover-
ing of the capital epiphysis
Fig. 3a, b. Lateral radiographs of the right (a) and left (b) hips
illustrating posterior slip of both capital epiphyses
including tennis and aerobic classes. Her gait is normal and she
has a pain-free fuctional range of motion in both hips (flexion
0~ ~ on each side without any extension). Abductor power
is normal on both sides. The lower limbs are of equal length.
There has been no further progression of radiographic changes
in the left hip joint (Fig. 5).
Discussion
Valgus slip of the femoral capital epiphysis was first
described by Mtiller in 1926, associated with acetabu-
lar dysplasia [8]. A valgus tilt of the capital femoral
337
epiphysis (so-called head-in-neck deformity) accom-
panying a horizontal or even laterally tilted growth
plate is a well-recognized iatrogenic deformity that
occurs during the treatment of congenital hip dysplasia
following prolonged casting in the Lorentz position
[10]. We consider this to be an entity distinct from
spontaneous reversed slipped capital femoral epiphysis
seen in adolescence. To our knowledge 12 cases of
true valgus slip have been described [1-5, 9, 11]; of
these, three were bilateral [3, 5].
The clinical and radiographic features in our pa-
tient strongly suggested that a progressive acute-on-
chronic slip had occurred in the presence of an open
growth plate in both hips. Further, both the degree of
containment and coverage were unacceptable. These
considerations led us to decide that an intertrochan-
teric osteotomy should be combined with transfixion
of the capital epiphysis.
The Imhauser-Weber osteotomy for moderate to
severe posteromedial slip in which the major compo-
nent is posterior has gained wide acceptance in Europe
[6]. In planning the operation in this case we had to
make provision for correction of the lateral (valgus)
338
Fig. 5. Anteroposterior radiograph of pelvis and both hips 5
years postoperatively. On the left side there is slight loss of
superior joint space. The femoral head shows some deformity
compatible with previous avascular necrosis
c o m p o n e n t to the slip by an a p p r o p r i a t e varus osteo-
tomy. S o m e authors have cautioned against osteoto-
mies in excess of 20 ~ which are thought to lead to per-
m a n e n t limp or unsteadiness [10]. Muller [7] has de-
scribed varus corrections varying f r o m 10 ~ to 40 ~ T h e
o s t e o t o m y was p l a n n e d to allow shortening of the
neck and distal transfer of the greater t r o c h a n t e r to
e n h a n c e a b d u c t o r function, and to result in ultimate
equalization of leg length u p o n correction of the op-
posite hip.
T h e segmental avascular necrosis which developed
in the left f e m o r a l h e a d was possibly related to the
n e e d for further surgery. Nevertheless, the result at
5-year follow-up was very good.
Because of the rarity of the condition it is not pos-
sible to postulate a p a t h o g e n e t i c m e c h a n i s m for re-
versed slip. Skinner and B e r k h e i m e r [9] have suggest-
ed an increased neck shaft angle m a y predispose to
M.A. Scher et al.: Bilateral Reversed Slipped Capital Femoral Epiphysis
Fig. 4a, b. Preoperative planning
diagrams of the right hip: a An-
teroposterior plan to allow for 35~
varus, shortening of the femoral
neck and distalization of the
greater trochanter; b lateral plan
giving 20~ of flexion and transfix-
ion of the capital epiphysis with a
35-mm cancellous screw. Overall
femoral shortening was calculated
as 22 mm
the condition. This was certainly p r e s e n t in our case,
as well as in others in the literature [2, 3, 9, 11]. In all
probability there exist a n u m b e r of aetiological fac-
tors. A n increased neck shaft angle is p r e s e n t in s o m e
patients with congenital dislocation of the hip, con-
genital m u s c u l a r atonia or spastic cerebral palsy with
a d d u c t o r d o m i n a n c e [10], despite which r e v e r s e d slip
is not e n c o u n t e r e d .
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Received May 30, 1988 / Accepted March 23, 1989