Abstract
Aim
To determine the preferred practices in the treatment of slipped capital femoral epiphysis (SCFE) among members of the Paediatric Orthopaedic Society of India (POSI).
Materials and Methods
A questionnaire with 16 vignettes was made about SCFE and sent to all members of the Paediatric Orthopaedic Society of India (POSI) to study the similarity and variation in the management of SCFE. Specifically, respondents were asked about the role of reduction, methods of fixation, prophylactic fixation of the non-affected hip, postoperative management and their view on the prevalence of Femoro Acetabular Impingement (FAI) and anticipated need for secondary surgery.
Results
The response rate was 94 out of 203 members of Paediatric Orthopaedic Surgeons of India (51.9%). 62 out of 94 (66%) participating surgeons had an exclusive paediatric orthopaedics workload, with 61 surgeons (65%) having more than ten years of experience. Seventy-eight surgeons (83%) were most consistent in their advice for the management of stable slips based on severity. For severe stable slips, 67 surgeons (71%) recommended Modified Dunn procedure. Around 23% of the respondents preferred to do modified Dunn’s procedure for all unstable slips while the rest had different approaches to treat this. Single Partially threaded cancellous screw is the preferred implant for in-situ fixation, while a single screw and K wire construct is the preferred construct for in Modified Dunn’s procedure. Only 17(16%) of the responders do prophylactic pinning of the opposite hip regularly. Almost 90 responders (96%) do counsel parents about FAI in later stages of life.
Conclusion
Our study documents that about 70% of the practising paediatric orthopaedic surgeons prefer to do capital realignment procedure for severe stable slips. The treatment of unstable slips remains controversial without any consensus though about 70% believe that there is a role of gentle reduction or positional reduction or skeletal traction. About 50% of the respondents treat less than five slips a year and thus would not possible to generate high-quality evidence based on meagre numbers. This clearly shows that there is a need for developing a national SCFE registry to pool in all data which would help us to arrive at meaningful conclusions to arrive at the ideal management guidelines for SCFE.
Keywords: Slipped, Capital, Femoral, Epiphysis, POSI, Survey
1. Introduction
Slipped capital femoral epiphysis (SCFE) is one of the most common adolescent hip disorders and a steady increase in the incidence has been reported from many studies across the world.1, 2, 3, 4, 5, 6, 7 Though in-situ screw fixation remains the standard of care for slipped capital femoral epiphysis, there are increasing reports of the role of capital realignment procedures.8 There is a reported decrease in in-situ fixation and an increase in the number of open reduction and internal fixation as the primary procedure for SCFE over the last decade.9
There are several areas of controversies in the management of SCFE and there are no clear guidelines on the management.10,11 Some of the areas of controversies are the role of gentle reduction versus open reduction in unstable slips, ideal implant used for stabilising the slip and the role of prophylactic fixation of the contralateral hip. The other important aspect which has changed significantly over the years is the use of advanced imaging modalities like the CT Scan and the MRI to assess the exact degree of slip rather than relying on the two-dimensional radiographs for decision making. Also, in this era of hip impingement, it becomes essential to know the incidence of post-SCFE Femoro-acetabular impingement (FAI) and the role of pre-operative counselling regarding the same. With this background, this study was conducted to find out the practice preferences of paediatric orthopaedic surgeons in managing a patient presenting with SCFE.
2. Materials and Methods
An elaborate questionnaire (e component content 1) containing 16 questions was carefully designed. The questionnaire had questions regarding clinical scenarios related to SCFE management about their practice of additional imaging practice, treatment in unstable slips, treatment based on the severity of slip, the practice of prophylactic pinning of opposite hips, their implant of choice and the incidence of femoro-acetabular impingement secondary to SCFE in their practice.
A Link of the questionnaire compiled in Google forms was sent to all members of POSI (Paediatric Orthopaedic Society of India). Completed questionnaires were tabulated in an excel sheet. Non-respondents were sent a reminder e-mail weekly once for three months duration. Surgeons were asked to provide basic information regarding their professional background, place of work, exposure of paediatric orthopaedics in practice, their training in paediatric fellowship and the number of SCFE patients being treated by them per year.
3. Results
Out of e-mail contacts of 203 members of the Paediatric Orthopaedic Society of India, 17 were non-functional and 5 were wrong e-mail contacts. Of the remaining 181 contacts, 94 responded to the email and filled in the forms and hence our response rate was 94/181 (51.9%).
3.1. Type of practice
Forty-one of the respondents (44%) had an institution-based practice while remaining had some form of private practice in their work schedule. Among the respondents, 62(66%) of them practised paediatric orthopaedics exclusively while remaining 32(34%) of them had a combined practice along with other specialities of Orthopaedics. Most of the respondents were in the status of consultant or equivalent (98%) levels in practice.80 of them (85%) had a formal fellowship in Paediatric Orthopaedics and a majority of the 61 respondents (65%) had an experience of 10 years and more in Paediatric Orthopaedics.
Only ten respondents treat more than 10 cases per year, while 45 (48%) of the respondents treat less than five patients a year.
3.2. Pre-op planning
About 77(82%) of the respondents opined that they would prefer to get additional imaging done as a part of the pre-operative evaluation of SCFE. 21(22%) of these respondents said that they would routinely do additional imaging in all SCFE related scenarios while 56 (59.5%) of them said that they would do additional imaging in selected cases. MRI 30/77(42%) was the most common choice of advanced imaging, and a combination of CT with MRI 23/77 (24%) was the next preferred choice (Fig. 1).
Fig. 1.
Preoperative planning - Additional investigations.
3.3. Operative management
3.3.1. Unstable slips
There is a wide variation amongst the respondents in the treatment of unstable slips. About 22 (23%) of them would prefer to do a capital realignment procedure (Modified Dunn’s Procedure) right away for all unstable slips while 21(22%) would attempt to do positional reduction and then decide on-table the further management based on the severity of slip. Another 19(20%) would do emergency positional reduction and screw fixation, 14(14%) opted to perform a gentle manipulative reduction and screw fixation,14(14%) opted for traction followed by in situ screw fixation. About 4(4%) of them would do an open reduction by Parsch method followed by screw fixation.
3.3.2. Stable slips
There was a higher level of agreement with the management of stable slips among the respondents and 78(83.5%) of them said that the management would change based on the severity of the slip. The rest 16(16.5%) of the respondents felt the severity of slip does not change their management protocol and they would do in-situ screw fixation of the slip irrespective of the severity at presentation.
For mild stable slips, 88(93.6%; 95%Confidence Interval (CI) 86–97%) of the respondents would do an in-situ screw fixation and the remaining 6(6.4%) of them preferred to add primary osteochondroplasty along with in-situ screw fixation.
For moderate stable slips, only 50(53.1%; 95%CI 43–62%) of the respondents agreed for an in-situ screw fixation as their mode of management while 18(19.1%) of them preferred doing an Osteochondroplasty along with primary screw fixation and 21(22.3%) of the respondents preferred doing Capital Realignment by Modified Dunn procedure. Five respondents (5.5%) did not reply to this question.
For severe stable slip, 67(71.2%; 95%CI 61–79%) respondents said that they would perform Capital Realignment procedure, while 11(11.7%) answered Osteochondroplasty with in-situ screw fixation and 10(10.6%) of them opined that in-situ screw fixation would be sufficient. Four surgeons (4.3%) did not reply to this question.
3.4. Prophylactic pinning of the opposite hip
Only 15(16%) of the respondents said that they would do prophylactic pinning of the opposite hip on a routine basis.
3.5. Implant of choice
In situ fixation: Single Cancellous screw remains the preferred implant of choice among 85(90%) respondents in treating SCFE. Majority Respondents 47(49%) prefer partially threaded single cancellous screws while 38(41%) use fully threaded single cancellous screw and 9(10%) of them use two or more screws in the fixation method (Fig. 2). Only 1 of the responders (1.1%) uses a non-cannulated screw system in treating SCFE while other 93 (98.9%) use a cannulated screw system.
Fig. 2.
Implant of choice.
Modified Dunn’s procedure (capital realignment): While 36(37.2%) of the respondents prefer single cancellous screw as the method of fixation, up to 8(8.5%) prefer to have two cancellous screws. Forty-three (44.7%) of them prefer to have screw and K wire in combination as the mode of fixation. 7(7.5%) prefer only K wires. Two (2%) respondents did not respond to this question.
3.6. FAI
Most of the respondents (96%) did counsel their patients about the possibility of development of symptomatic FAI later in life and the need for prolonged follow-up and 72% of them replied that they see Femoroacetabular impingement morphology in their clinical follow-up of slipped capital femoral epiphysis cases.
4. Discussion
Slipped Capital Femoral epiphysis is one of the common adolescent hip problem.1, 2, 3, 4, 5, 6, 7 Many controversies are surrounding the evaluation and management of SCFE. The evolution of newer concepts of FAI and treatment modalities like capital realignment and primary osteochondroplasty has unfortunately not led to clear guidelines for management and instead has increased the number of treatment options available, thereby increasing the controversies. Questionnaire studies on the treatment of unstable SCFE have already been published.11,12 This study was specifically done to know the practice preferences among the members of Paediatric Orthopaedic Society members of India about most of the controversies revolving around this condition. The data from this study certainly reflects the current treatment trends followed in India for this common condition. The current study is a questionnaire-based survey of various SCFE clinical scenarios to understand practice preferences. We had 94 surgeons respond to us and analysis revealed wide variation in practice among the Surgeons.
Of the 94 surgeons who responded to the survey, 62 of them practice exclusive Paediatric Orthopaedics hence we believe that this survey could be a good overall representation of practising paediatric orthopods across the country. The response rate for this study is around 46% which is better than the POSNA study (33%) but lesser than the British Paediatric Orthopaedic Society Survey (65%).11,12
Seventy-seven of the 94 surgeons (82%) opined that they would go for additional advanced imaging in SCFE scenarios with MRI being the most common one. All of the private practitioners (17/17) would get additional imaging for decision making in SCFE.
4.1. Treatment of stable SCFE
There was little variability in the treatment of stable slips for which more than 80% of them said that they would decide the management based on the severity of slip. While all of them agreed for in-situ fixation for mild stable slips, the concept of primary osteochondroplasty seems unpopular among the POSI members.
The treatment of moderate stable slips remains controversial. While around 50% of the surgeons opined that they would just do in-situ screw fixation the rest 50% was equally divided between additional primary osteochondroplasty and modified Dunn’s capital realignment procedure. It is interesting to note that 6% of the surgeons did not give any response to this question, which again points out that this is a big dilemma in the surgeon’s mind.
As far as the severe stable slips are concerned around 70% of surgeons have said that they would do a modified Dunn’s capital realignment procedure. This is a considerable shift in the philosophy of care for stable SCFE where in-situ screw fixation remained the standard of care. The capital realignment procedure or the modified Dunn’s procedure through the safe surgical dislocation approach is a technically demanding operation to achieve anatomic correction even in severe slips.
4.2. Treatment of unstable SCFE
It is interesting to note that 70% of the surgeons would attempt some form of closed reduction of the slip in an unstable scenario which is contrary to the classical teaching of no role for reduction in SCFE. About 23% of the surgeons preferred to a capital realignment by modified Dunn’s procure through safe surgical dislocation approach for all unstable slips. This is strikingly different from the surveys done among the EPOS members, where only 10(11%) preferred for capital realignment. It is to be noted that EPOS survey was done in 2011 during a period where the technique was not popular after its first description in 2009.13 We believe that this variation in period could be one of the possible reasons for this difference similar to any new procedure which takes time to get popular and being commonly used. Among the 62 surgeons who had more than ten years’ experience in our study only 13 of them (21%) would perform a Modified Dunn procedure while 5/18 (28%) of younger surgeons would perform the procedure indicating that both experienced and younger surgeons were equally interested in doing capital realignment procedure.
Of the respondents who preferred capital realignment as the treatment in Moderate and Severe slips 18/21(86%) of them had an Institutional practice and 3/21(14%) had a private practice. This indicates that surgeons in institutional practice tend to do more complex reconstructive procedures than those in private practice.
4.3. Variability in implant of choice
Though there is adequate scientific evidence of a single cancellous screw being a very stable construct of fixation in SCFE, 9(10%)of the respondents prefer to use two screws for stabilising the femoral head.14 Almost all, except one of the 93 responders (98%)use a cannulated cancellous screw system for the fixation, which is technically easier compared to the non-cannulated system.
4.4. Variability in Fixing Contralateral hip
Only 15(16%) of the respondents felt there was a need to fix contralateral hip (Fig. 3). This seems almost comparable to the POSNA study (12%) and British Paediatric Orthopaedic Society Surgeons survey (9%).11,12 Majority 12 out of 16 respondents (75%) who fixed contralateral hip were engaged in Institutional practice.
Fig. 3.
Variability in Fixing Contra lateral hip.
4.5. Limitations of the study
Our response rate of the study was around 51.9% which is low and need not reflect the actual practice preferences of vast majority of surgeons. Since the questionnaire was sent as an e-mail, there is a possibility of it being missed as a Junk mail.
5. Conclusion
Within the POSI members, there are considerable variabilities in the management of SCFE. In-situ screw fixation does not remain as the gold standard in the treatment of SCFE as newer techniques like capital realignment procedure and primary osteochondroplasty have come into vogue with the new knowledge gained about femoro-acetabular impingement. Our study documents that about 70% of the practising paediatric orthopods prefer to do capital realignment procedure for severe stable slips. The treatment of unstable slips remains controversial without any consensus though about 70% believe that there is a role of gentle reduction or positional reduction or skeletal traction. About 50% of the respondents treat less than five slips a year and thus it would not be possible to generate high-quality evidence based on meagre numbers. This clearly shows that there is a need for developing national SCFE registry and multicentre studies which would help us develop the ideal management guidelines for SCFE.
Declaration of competing interest
None.
Footnotes
Supplementary data to this article can be found online at https://doi.org/10.1016/j.jcot.2020.04.029.
Contributor Information
S.P. Sivakumar, Email: drspsiva@gmail.com.
K. Venkatadass, Email: venkatpedortho@gmail.com.
S. Rajasekaran, Email: rajasekaran.orth@gmail.com.
Appendix A. Supplementary data
The following is the Supplementary data to this article:
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