Slipped capital femoral epiphysis: a spectrum of surgical care and changes over time

Abstract

Purpose: To survey the spectrum of surgical care in children with slipped capital femoral epiphysis (SCFE). This information is valuable in counselling the patient about the future treatment course.

Methods: Data for this study were obtained from the Pediatric Hospital Information System (PHIS) between 2004 and 2015. For all patients with an ICD9 diagnosis of 732.2, gender, ethnicity, hospital, medical record number, date of birth/admission/discharge, type of admission, length of stay, disposition and treatment(s) rendered were collected.

Results: A total of 13 168 procedures were performed in 11 058 unique SCFE patients, or 1.2 procedures per patient. Primary procedures were those performed for the initial treatment of the SCFE and secondary procedures as reconstructive and salvage. The majority (11 693, 88.8%) were primary. There was significant variation in the ratio of primary and secondary procedures by institution. There was a decline in in situ fixation as the initial SCFE treatment with an increase in open reduction and internal fixation over the 12-year span. Similarly, there was a significant increase in the number of secondary procedures over time as well as complications and implant removal. There was no change over time in the diagnosis of avascular necrosis.

Conclusions: The average number of surgical procedures in patients was in the range of 1 to 6 and varied widely by hospital. Each physician should know his/her own hospital's data for the percentage of subsequent procedures so as to counsel the patient and family properly. The increasing number of complications over time may reflect the increasing number of more complex procedures.

Keywords: SCFE; avascular necrosis; complications; slipped capital femoral epiphysis; treatment.

Fig. 1

Primary and secondary procedures for SCFE between different children’s hospitals. The lowest proportion of primary procedures was hospital A (64.4%) and the highest was hospital AW (97.8%). This difference was statistically significant, p < 10^-6.

Fig. 2

Increasing proportion of secondary procedures for SCFE over time. The best fit equation is represented by the equation: percentage of secondary procedures = -12.77 + 0.608 (year), r = 0.88, p = 0.000008. The number of secondary procedures for each year is shown by the filled rhomboids and the best fit linear regression the bold line.

Fig. 3

Increasing proportion of procedures due to complications of SCFE treatment over time. The overall prevalence of complications for each year is shown by the filled rhomboids and the best fit a solid line represented by the equation: percentage = -509.3 + 0.255 (year), r = 0.79, p = 0.00023. The percentage of implant removal for each year is shown by the open triangles and the best fit is shown by the long hatched line, represented by the equation: percentage = -349.31 + 0.175 (year), r = 0.56, p = 0.008. The percentage of avascular necrosis for each year is shown by the open circles and the best fit is shown by the short hatched line, represented by the equation: percentage = -51.95 + 0.026 (year), r = 0.28, p = 0.15.

Fig. 4

Graphs demonstrating changes over time for the initial treatment in children with SCFE. (a) A decrease in both internal fixation in situ and epiphyseodesis as the initial treatment of SCFE over time. For internal fixation in situ, the percentage of cases is shown in solid squares and the best fit linear regression the bold line, represented by the equation: percentage of cases = 1607 - 0.7651 (year), r = 0.56, p = 0.0058. For epiphysiodesis, percentage of cases is shown in open triangles and the best fit linear regression is shown by the dotted line represented by the equation: percentage of cases = 283.5 – 0.140 (year), r = 0.62, p = 0.002. (b) An increase in open reduction internal fixation as the initial treatment of SCFE over time. The percentage of cases is shown by the filled rhomboids and the best fit linear regression the solid line, represented by the equation: percentage of cases = -1315 + 0.657 (year), r = 0.90, p = 0.00002.