Patients and Methods: The research was performed based on the study of the following variables: clinical patient history, symptomatology and physical findings. Admission for anteroposterior (AP) view and Lauenstein [1] frog-leg position for lateral radiograph view of both hips (validated instrument) was performed. A retrospective review maintained data base of patients diagnosed with valgus SCFE was conducted. Patients with radiographically valgus SCFE were identified, confirmed and in the analysis, included. Medical records for clinical features, treatment, and outcomes, were reviewed.
Results: Seven patients from the database were indentified: the patient average age at diagnosis was ten years and six months old, within follow up time of thirty six months. All valgus SCFE patients with localized disease with conservative treatment using cast immobilization were managed. Two hips showed evidences of chondrolysis; however just one patient presented juvenile rheumatoid arthritis (JRA) disease diagnosed.
Conclusions: The hip joint in our series treated by plaster cast immobilization method to control the progressive valgus displacement of the epiphysis was effective and capable of being justified, and functional. Chondrolysis and its link as a complication were described. This research is justified by the importance and attention that the entity deserves.
Keywords: SCFE; Coxa Valga; Plaster Cast Immobilization
Ambroise Paré [4], Sabatier, M. Mémoire Sur la Fracture du Col du Fémur The first investigation description about the word spica in old French was published.[5].
“On fait le fpica avec une bande longue de quatre ou cinq aunes roulée à um chef le globe paffe plufieurs fois fous la cuiffe malade pour le faire revenir fur le grand trochanter, & leconduire enfuite autour du corps Celui dont plus nombre des Auteurs recommande l’ufage eft le fpica...
Walther Müller introduced, in March 2, 1926, from the Surgical University Clinic of Marburg, descriptions, illustrations, interpretations, comments, and observations of the Coxa valga forms (lateral and upward displacement of the epiphysis against the femoral neck).[6] There is no explanation for the formation of the Coxa valga adolescentium. The displacement of the femoral head on the metaphysis in the literature is little discussed. This process of lateral displacement of the epiphysis on the femoral neck, in fact, represents the key to the explanation of most forms of the Coxa valga. The genesis was not yet clarified at all. Müller report epiphyseal Coxa valga in patients with coexisting acetabular dysplasia. In several parameters the articles from world literature, the authors did not report the subject matter from the demographic data of valgus SCFE.
The authors, in 2017, presented seven more patients with valgus SCFE (eight hips). A female patient had the right hip treated by spica cast immobilization. The other female patient (left hip) had bilateral long casts (with cross bar-struts) employed. A male patient (both hips) and a female patient (left hip) had the hips treated by short casts in abduction with antirotational bars. A male patient (left hip) and two female patients (both left hips) had the hips with bilateral short casts in abduction and internal rotation of about 30’ with cross bar-struts applied.
Detailed information from the literature investigated, baseline demographic characteristics of included 69 patients with 89 valgus SCFEs on (Table 1) are reported.
Year |
Author |
Patient |
Sex |
Age at Diagnosis (Yrs.) |
Race |
Hip R/L |
Weight (kg) |
Stability |
IR |
ER |
ABD |
FLEX |
Type |
Grade |
Treatment |
Complications |
1926 |
Müller6 |
-- |
-- |
-- |
-- |
-- |
-- |
-- |
-- |
-- |
-- |
-- |
-- |
-- |
-- |
-- |
1930 |
Scheuermann7 |
One |
F |
14 |
-- |
R |
-- |
-- |
-- |
-- |
-- |
-- |
-- |
-- |
Confinement to bed for 2 months |
-- |
1946 |
Finch and Roberts8 |
F |
14 |
N-W |
R+L |
-- |
-- |
-- / 10o |
15o / -- |
-- / -- |
-- / -- |
Ch / Ch |
-- / -- |
Bilateral long-leg casts in IR / abduction of 300 Adhesive traction for 8 weeks + right hip spica for six weeks |
Avascular necrosis |
|
1949 |
Howorth9 |
Two |
F |
13 |
N-W |
R+L |
-- |
-- / -- |
-- / -- |
-- / -- |
-- |
Ch / -- |
-- / -- |
-- |
||
1950 |
Jerre10 |
Three |
-- |
-- |
-- |
3 |
-- |
-- |
-- |
-- |
-- |
-- |
-- |
-- |
-- |
-- |
1957 |
Meyer et al11 |
Four |
-- |
-- |
-- |
7 |
-- |
-- |
-- |
-- |
-- |
-- |
-- |
3 slight |
Different forms of treatment |
5 arthrosis deformans |
1965 |
Fahey and O´Brien12 |
4 marked |
|
|||||||||||||
1965 |
Wilson et al13 |
Two |
F |
13 |
W |
L |
-- |
-- |
-- |
-- |
-- |
-- |
Ch |
-- |
Manipulation and well-leg traction |
Some limitation of IR |
1970 |
Schott and Vianna14 |
-- |
-- |
-- |
-- |
-- |
-- |
-- |
-- |
-- |
-- |
-- |
Non weight bearing on crutches |
Some limitation of IR |
||
1972 |
Krishan and Shelton15 |
One |
F |
11.8 |
W |
R |
-- |
-- |
-- |
-- |
-- |
-- |
AcCh |
-- |
Gentle traction + fixation with 2 threaded pins |
Sclerotic changes+ regression |
1972 |
Mihran O. Tachdjian16 |
Two |
F |
12 |
-- |
L |
-- |
-- |
-- |
-- |
-- |
-- |
-- |
-- |
-- |
-- |
1978 |
Skinner and Berkheimer17 |
-- |
-- |
-- |
-- |
-- |
-- |
-- |
-- |
-- |
-- |
-- |
-- |
-- |
-- |
|
1979 |
Rothermel 18 |
One |
F |
12 |
-- |
L |
-- |
-- |
-- |
-- |
-- |
-- |
Ac |
-- |
in situ three left Steinmann’ pins |
Chondrolysis+ hip joint restored |
1984 |
Carlioz et al19 |
One |
F |
11 |
N-W |
R+L |
-- |
-- |
300 / 300 |
450 / 450 |
--/-- |
700 / 900 |
Ch /Ch |
--/-- |
in situ three Knowles’ pins of the right hip |
--/-- |
1989 |
Scher et al20 |
in situ three Knowles’ pins of the left hip |
--/-- |
|||||||||||||
1996 |
Segal et al21 |
F |
-- |
-- |
R+L |
-- |
-- |
-- |
-- |
-- |
-- |
RI /LII |
in situ two Knowles’ pins of the left hip. Two threaded pins + spica cast + crutches + varization osteotomy |
--/-- |
||
2003 |
Rajan et al22 |
Two |
M |
13 |
N-W |
R |
-- |
-- |
-- |
-- |
-- |
-- |
-- |
-- |
Two threaded pins out of the neck + pins removed |
|
2004 |
Docquier et al23 |
One |
M |
12 |
N-W |
R |
-- |
-- |
-- |
-- |
-- |
60o |
Ch |
-- |
in situ three Knowles’pins of the right hip |
-- |
2005 |
Yngve et al24 |
One |
M |
15 |
W |
R |
-- |
-- |
-- |
-- |
-- |
10o |
Ch |
-- |
in situ four Knowles’pins of the right hip |
-- |
2006 |
Loder et al3 |
Two |
F |
14 |
-- |
L |
-- |
-- |
-- |
-- |
-- |
-- |
Ch |
-- |
in situ left screw fixation |
-- |
2007 |
Shea et al25 |
F |
13 |
-- |
R |
-- |
-- |
-- |
-- |
-- |
Ch |
-- |
in situ right screw fixation |
-- |
||
2010 |
Mata and Ovejero26 |
One |
F |
14 |
-- |
R+L |
56 |
-- |
-- |
-- |
-- |
1000 / 900 |
AcCh |
-- |
Imhauser-Weber osteotomies |
L femoral head segmental a vascular necrosis |
2010 |
Shank et al27 |
AcCh |
||||||||||||||
2011 |
Renganathan et al28 |
F |
9.9 |
W |
R |
36 |
1 Stable |
-- |
-- |
-- |
-- |
Ac |
III |
in situ right cingulated screw fixation |
-- |
|
2011 |
Venkatadass et al29 |
Two |
F |
10.11 |
N-W |
R |
91 |
1 Stable |
0 |
300 |
300 |
400 |
Ch |
III |
in situ right cannulated screw fixation |
-- |
2013 |
Koczewski30 |
|||||||||||||||
2017 |
Kotoura et al31 |
One |
F |
10 |
-- |
R |
-- |
1 Stable |
reduced |
-- |
reduced |
reduced |
Ch |
-- |
An adductor tenotomy + varus osteotomy+ Richards’ screw and hip spica |
-- |
To qualify this study, valgus hip SCFE and painful condition in the hip had been the characteristic deformity. Radiographs (type of imaging) remains the gold standards used as validated instruments (important tools) to improve medical care in daily clinical practice and by modifying treatment protocols were the basis of the results. The outcome instruments, focused on biological and physiological factors in orthopedic research were considered. The valgus SCFE patient’s sex, race, weight, hip treated, age at diagnosis, time in a cast and the type of cast were recorded. The methods used were based on symptomatology, and categorized as acute (symptoms for < 3 weeks), chronic (symptoms for ≥ 3 weeks), and acute-on-chronic (chronic symptoms, complaints initially and the subsequent exacerbation of acute symptoms); according to Fahey and O’Brien criteria were evaluated. Slip degrees were documented by the standard method of thirds and classified as mild (<33%), moderate (33% to 50%), or severe (>50%), according to Wilson, Jacobs, Schecter, MacEwen and Ramsey, who use the three grades (<30%) (30%-50%), (>50%) of slip percentage [12,13,33]. The hips were evaluated systematically roentgenographically as well as functionally, according to Heyman and Herdon’s criteria, and were also categorized as satisfactory and unsatisfactory by means of Aadalen, Weiner, Hoyt, Herdon and Herdon’s criteria [34,35]. Methods to analyze the joint cartilage and detect chondrolysis were utilized based on Ingram, Clarke, Clark and Marshall’s criteria [36]. Chondrolysis leads to deformity, pain, and limp, limitation of motion in the hip and narrowing of the joint space affected according to radiographies criterion if the joint space measured 3mm or less, then chondrolysis was present. The type of SCFE as stable or unstable was classified [37]. A stable SCFE is defined when the patient is able to ambulate, with or without crutches. An unstable SCFE is classified when the patient, with or without crutches cannot ambulate. The lack of intersection between a line draw parallel to the superior edge of the femoral neck (Klein’s Line) and the epiphysis confirms a slip [38]. In valgus SCFE, the Klien line will always be normal [3]. For an opportune diagnosis The Klein’s line, therefore, the Lauenstein frog-leg position for the lateral radiograph view of both hips are absolutely necessary [1]. Weight category was based on 2000 CDC Growth Charts for the United States: Methods and Development [39]. The method of treatment of the valgus SCFE, in this project the immobilization in a spica cast and bilateral long/ short leg casts in abduction internal rotation with antirotational bars has been applied. The protocol period for immobilizing the patient’s hip for twelve weeks, was established.
The inferential analysis for comparison between the two SCFE (classic and valgus) subgroups by the Fisher accurate test in the categorical data and by the Mann-Whitney U test (non parametric) in the numeric data was composed. The association among the characteristics of the hips affected by chondrolysis complication by the qui-square (χ2) test or by the Fisher accurate test was analyzed.
The non parametric method, because the variables did not present normal distribution (Gaussian distribution), due to the rejection of the normality hypothesis according to the Shapiro- Wilk test was used. The determination criterion of the significance was at 5% level was adopted. The statistical analysis by the statistical software SAS® System, version 6.04 (SAS Institute, Inc., Cary, North Carolina) was processed.
Summary of clinical and characteristics parameters of valgus SCFE (author’s own series) in table 2 is described. Proximal Femoral angular measurements in patients with valgus SCFE in table 3 is observed.
Case |
Age at Diagnosis (Yrs) |
Sex* |
Race# |
Hip Treated¥ |
Weight kg |
Classification Fahey and O’Brien33 |
Grade Of Slip Wilson. Jacobs. |
Stability Loder et al39 |
Time in Cast (Days) |
Type of cast |
Complications |
Functional evaluation criteria of Heyman/ Herdon36 and Aadalen37 |
Follow up analysis (months) |
1 |
11.7 |
F |
N-W |
R |
49 |
Acute |
Mild |
Stable |
116 |
1 ½ Hip Spica |
JRA Chondrolyis |
Unsatisfactory |
77 |
2 |
11.8 |
F |
W |
L |
28 |
Acute |
Mild |
Unstable |
93 |
Bilateral Long Casts |
__________ |
Satisfactory |
21 |
3 |
11.4 |
M |
W |
R |
65 |
Chronic |
Mild |
Stable |
91 |
Bilateral Short Casts |
__________ |
Satisfactory |
58 |
L |
Chronic |
Mild |
Stable |
Satisfactory |
|
||||||||
4 |
9.1 |
F |
N-W |
R |
60 |
Acute |
Mild |
Stable |
94 |
Bilateral Short Casts |
__________ |
Satisfactory |
28 |
5 |
11.4 |
M |
N-W |
L |
50 |
Chronic |
Mild |
Stable |
90 |
Bilateral Short Casts |
__________ |
Satisfactory |
26 |
6 |
10.3 |
F |
N-W |
L |
36 |
Chronic |
Mild |
Stable |
93 |
Bilateral Short Casts |
Chondrolyis |
Unsatisfactory |
29 |
7 |
10.7 |
F |
N-W |
L |
50 |
Chronic |
Mild |
Stable |
90 |
Bilateral Short Casts |
_________ |
Satisfactory |
15 |
Case |
Flexion |
Abduction |
Adduction |
Internal Rotation |
External Rotation |
Comments |
|||||
Before |
Latest |
Before |
Latest |
Before |
Latest |
Before |
Latest |
Before |
Latest |
__________ |
|
1 |
(R) 30° |
0° |
20° |
0° |
10° |
0° |
10° |
0° |
20° |
0° |
Juvenile rhematoid arthritis |
Right hip(chondrolysis) |
|||||||||||
2 |
(L) 90° |
90° |
60° |
45° |
30° |
30° |
20° |
15° |
90° |
80° |
Idiopathic Valgus SCFE |
3 |
(R) 75° |
120° |
45° |
45° |
20° |
30° |
10° |
20° |
60° |
60° |
Bilateral Idiopathic |
(L) 80° |
120° |
45° |
45° |
20° |
30° |
15° |
20° |
60° |
60° |
Valgus SCFE |
|
4 |
(R) 90° |
90° |
35° |
60° |
30° |
30° |
15° |
15° |
80° |
60° |
Endocrine Dysfunction |
5 |
(L) 90° |
90° |
45° |
40° |
20° |
20° |
15° |
15° |
45° |
45° |
Idiopathic Valgus SCFE |
6 |
(L) 60° |
30° |
40° |
10° |
20° |
15° |
0° |
0° |
30° |
0° |
Left hip-Chondrolysis |
7 |
(L)100° |
90° |
45° |
45° |
20° |
20° |
20° |
20° |
60° |
45° |
Idiopathic Valgus SCFE |
Variable |
category |
Total |
SCFE |
|||||
Classic |
Valgus |
p value |
||||||
(n = 131) |
(n = 124) |
(n = 7) |
||||||
Clínical Characteristics |
||||||||
Age (years) |
||||||||
median (Q1 - Q3) |
|
12 (11 - 13) |
12 (11 - 13) |
11 (10 - 11) |
0,049 |
|||
Age-group - n (%) |
< 12 years |
68 |
51.9 |
61 |
49,2 |
7 |
100 |
0,009 |
≥ 12 years |
63 |
48.1 |
63 |
50,8 |
0 |
0 |
||
Sex- n (%) |
male |
71 |
54.2 |
69 |
55,6 |
2 |
28,6 |
0,16 |
female |
60 |
45.8 |
55 |
44,4 |
5 |
71,4 |
||
Race - n (%) |
white |
64 |
48.9 |
62 |
50,0 |
2 |
28,6 |
0,24 |
non-white |
67 |
51.1 |
62 |
50,0 |
5 |
71,4 |
||
Wheight (kg) |
||||||||
median (Q1 - Q3) |
|
62 (49 - 72) |
62 (50 - 74) |
49 (36 - 60) |
0,019 |
|||
Obese - n (%) |
yes |
86 |
65.6 |
84 |
67,7 |
2 |
2,9 |
0,046 |
no |
45 |
34.4 |
40 |
32,3 |
5 |
97,1 |
||
Patient side envolvement- n (%) |
right |
42 |
32.1 |
40 |
32,3 |
2 |
28,6 |
|
left |
54 |
41.2 |
51 |
41,1 |
3 |
42,9 |
0,99 |
|
bilateral |
35 |
26.7 |
33 |
26,6 |
2 |
28,6 |
||
Treatment and follow-up |
||||||||
Cast type- n (%) |
spica |
58 |
44.3 |
57 |
46,0 |
1 |
14,3 |
|
short cast |
72 |
55.0 |
66 |
53,2 |
6 |
85,7 |
0,18 |
|
crutches |
1 |
0.8 |
1 |
0,8 |
0 |
0,0 |
||
Time in cast (weeks) |
||||||||
median (Q1 - Q3) |
13 (12 - 13) |
13 (12 - 13) |
13 (12 - 14) |
0,35 |
||||
Follow up (months) |
|
|||||||
median (Q1 - Q3) |
34 (13 - 57) |
35 (13 - 57) |
25 (12 - 70) |
0.92 |
Comments:
The subgroup with valgus SCFE have presented: age in years (p=0,049), age group ≥ 12 years (p=0,009), weight (p=0,019) and obesity (p=0,0046) significantly smaller than the subgroup with classic SCFE. The other clinical characteristics of the patients, between the two SFCE subgroups did not present significant differences at 5% level. Also the treatment characteristics and follow-up did not present significant differences at 5% level, between the two SCFE subgroups.
Obs: The interquartile interval (IIQ) have 50% of the observations between the limits which corresponds to 10 quartile (Q1) and 30 (Q3). This interval as a measure dispersion which follows the median (as the standard deviation follows the medium) it was obtained.
Variable |
category |
Total (n = 166) |
SCFE |
p value |
||||
Classic (n = 157) |
Valgus (n = 8) |
|||||||
Hip Joint Characteristics |
||||||||
Hip Side - n (%) |
right |
77 |
46,4 |
74 |
46,8 |
3 |
37,5 |
0,44 |
left |
89 |
53,6 |
84 |
53,2 |
5 |
62,5 |
||
Symptomatology - n (%) |
acute |
26 |
15,7 |
23 |
14,6 |
3 |
37,5 |
0,17 |
cronic |
131 |
78,9 |
126 |
79,7 |
5 |
62,5 |
||
acute-on cronic |
9 |
5,4 |
9 |
5,7 |
0 |
0,0 |
||
Stability - n (%) |
stable |
151 |
91,0 |
143 |
90,5 |
8 |
100,0 |
0,46 |
unstable |
15 |
9,0 |
15 |
9,5 |
0 |
0,0 |
||
Slip degrees - n (%) |
mild |
119 |
71,7 |
111 |
70,2 |
8 |
100,0 |
0,74 |
moderate |
28 |
16,9 |
28 |
17,8 |
0 |
0,0 |
||
severe |
19 |
11,4 |
19 |
12,0 |
0 |
0,0 |
||
Complication - n (%) |
right chondrolysis |
8 |
4,8 |
7 |
4,4 |
1 |
12,5 |
0,19 |
left chondrolysis |
9 |
5,4 |
8 |
5,1 |
1 |
12,5 |
||
no complication |
149 |
89,8 |
143 |
90,5 |
6 |
75,0 |
Results of the patients with valgus slipped capital femoral epiphysis (SCFE) by plaster cast immobilization treatment were performed. (Cases 1, 2, 3, 4, 5, 6, 7)
Distribution of the seven cases with valgus SCFE. Radiographs and pictures of the patients during follow-up treatment, Cases 1,2,3,4,5,6,7 was demonstrated.(Figures 1-7)
The routine methodology in current report on conservative principle with the use of spica cast immobilization in accordance with Betz et al protocol and bilateral short/long leg casts in abduction, slight internal rotation (30o) with antirotational bars based on Kite; Wright, et al and King works was used[41- 44]. Cast immobilization for 12 weeks, in accordance with the casting protocol was carried out. No weight-bearing during the “casting period” was permitted. One case of Waldenström’s disease associated with poly-articular rheumatoid with the use of spica cast immobilization was observed. Moule and Golding the appearance of hip changes in a patient with polyarticular rheumatoid disease (Still´s disease) associated with coxa valga have been described [45,46]. The manifestation and prevalence of chondrolysis as complication in female and nonwhite patients are some of the unclarified points in the literature [32]. Wright et al and King presented 52 cases with the use of bilateral short-leg cast immobilization as a form of treatment for SCFE without chondrolysis [43,44]. Regarding the frequency of development of chondrolysis in non-white patients with the diagnosis of SCFE, we think that cast immobilization, at least, is not the major factor in the development of this complication [47]. Pinheiro [32] used cast treatment for SCFE (106 hip joints) and had 11.3% of chondrolysis as complication [32]. Betz et al 41 with spica-cast immobilization in 37 hips had five hips (13.5%) with chondrolysis. Ingram et al the incidence of chondrolysis varies from 2% to 55%. It may occur after any type of treatment, whether conservative or operative [48,49]. In summary, the cause of chondrolysis after SCFE still remains obscure and their genesis either not yet clarified at all [49].
Note: Skinner and Berkheimer [17] in his article observed a patient with a right valgus slip with contralateral varus, probably the first case in the orthopedic literature [17]. Venkatadass et al also have shown varus of the right (1 year ago) and valgus of the left the hip treated with two 6.5mm partially threaded cancellous screws in both hips (second case) [29]. Kotoura et al presented the third case with right valgus SCFE and left typical varus SCFE [31]. In our sample we had a patient (Case 7) with a varus of the right and valgus SCFE of the left hip. Presumably the fourth varus + valgus patient in the literature published.
The clinical characteristic scope of valgus SCFE has permitted new relations and discoveries and for this reason each main topic will be separately discussed.
In conclusion, we judged that cast treatment for SCFE’s (classic/valgus) was productive, functional, competent and it can be used for services with the difficulties of using a safe surgical procedure with appropriate fluoroscopy (X- ray machine) and cannulated screws for slipping fixation as a method of treatment.
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