Uniformity of management is particularly unusual in the specialty of pediatric orthopaedics, where a range of treatment options is often available for the conditions that we treat, resting on a tenuous foundation of scientific evidence. SCFE is one of the most common pediatric orthopaedic conditions that we see not only in teaching centres, but also in every community hospital across Canada. The majority of these patients will not be managed by pediatric orthopaedic specialists with expertise in complex hip surgery. <\/p>\n
It is therefore of legitimate concern that controversy once again surrounds the treatment of unstable SCFE with the emergence of surgical hip dislocation and open reduction and internal fixation (ORIF) as an alternative to ISSF.<\/p>\n
A review of the literature on the topic of SCFE reveals a wealth of research that is unfortunately limited to mostly Level IV or V studies.<\/sup> A variety of treatment strategies have been described, including operative and non-operative management.3-5<\/sup> ISSF has risen above all other strategies as a reliable and safe procedure with a low complication rate.5,6<\/sup> Without a formal reduction maneuver, some gentle internal rotation whilst positioning the limb may effect a modest reduction of the SCFE, minimizing the severity of the slip, prior to percutaneous screw fixation.<\/p>\n \nThe near-universal adoption of ISSF is likely due to the fact that it relies on equipment and implants being available at most institutions and a surgical technique that is transferable from other common orthopaedic procedures. Within a training program it is easily taught and supervised, while in the community setting it can be performed with minimal surgical assistance. <\/p>\n Advocates of ISSF have continued to modify the technique, improving the procedure to address several technical issues. Modern imaging methods have improved the accuracy of screw placement to minimize the risk of joint penetration and the risk of AVN or chondrolysis.<\/sup> The use of two image intensifiers for biplanar fluoroscopy or a 3D CT C-arm are new additions to the radiographic armamentarium to improve procedural accuracy. Previous issues with the internal fixation devices have been reduced with the use of cannulated screw fixation in preference to multiple pins. Complications related to screw removal are likely to be improved with the demonstration that fully threaded screws may offer some advantages to their partially threaded counterparts.8,9<\/sup> Recent work has brought attention to the increased intra-capsular pressure that exists in cases of unstable SCFE.10<\/sup> The release of this hematoma through an anterior or lateral approach can decrease the intra-capsular pressure and potentially decrease the risk of avascular necrosis. The improvements of the classic ISSF to a more contemporary version have addressed many key concerns and have improved an already successful treatment strategy.<\/p>\n Orthopaedic surgeons should not feel that they are offering substandard treatment by way of ISSF. There is very little, if any, evidence to justify the benefits of the alternative experimental procedure of surgical hip dislocation and ORIF over the established gold standard. Surgical hip dislocation is a technically challenging procedure with potentially devastating complications and limited options for salvage. Though there is intuitive benefit to an anatomic reduction to prevent the sequelae of femoroacetabular impingement, the outcomes of the technique are as yet unproven. <\/p>\n There will almost certainly be a place for more complex reconstructive procedures of the hip in SCFE, although we firmly believe that any new procedure should be subject to the rigours of scientific scrutiny in the setting of clinical trials. Should surgical hip dislocation and ORIF prove to be at least as efficacious as ISSF for the treatment of unstable SCFE, with an equally low morbidity and complication rate and similar reproducibility, it should then be widely adopted. Until then, the gold standard of treatment of unstable SCFE should remain as contemporary ISSF.<\/p>\n Reprinted with permission from the Winter 2010 issue of COA Bulletin<\/em><\/p>\n![](\"http:\/\/www.orthopaedicsone.com\/viewpoints\/wp-content\/uploads\/sites\/12\/2024\/06\/grey_arrow_down.gif\"){kind=icon}
<\/span>Read more…<\/span><\/p>\n
\nFigure 1.<\/strong> 13-year-old male with a three-month history of mild left groin pain, suddenly increasing in severity over 24 hours, and inability to weight bear. Managed by gentle internal rotation of the limb while positioning, capsulotomy and in-situ screw fixation with a 7.3 mm fully threaded cannulated screw. Images show preop, immediate postop and three-month follow-up radiographs.<\/p>\nReferences<\/h3>\n
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Attachments:<\/h2>\n
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