Most patients with slipped capital femoral epiphysis (SCFE) do well after treatments such as pelvic osteotomies or in situ pinning. A small group, however, may continue to experience joint pain and eventually require additional surgical treatment to manage end-stage hip arthritis, osteonecrosis, or chondrolysis, said Rafael J. Sierra, MD, during the Pediatric Orthopaedic Society of North America 2012 Specialty Day.“In the SCFE patient, the need for subsequent surgery may increase with age and, eventually, if the patient lives long enough, some form of arthroplasty—either hip resurfacing or total hip arthroplasty (THA)—may be needed,” he said.

Arthroplasty patients with a history of SCFE are typically younger, are often females of child-bearing age, and may be obese, according to Dr. Sierra. His indications for arthroplasty in the SCFE population are young, active patients whose hip pain has not responded to nonsurgical management and interferes with the patient’s activity level and quality of life. He pointed out, however, that the anatomic features of the slip and femoral deformity can pose unique reconstructive challenges.

Resurfacing a less-than-ideal option
Hip resurfacing has the advantage of preserving bone, but it also has several disadvantages, including the following:

• Resurfacing is a more difficult procedure to perform than THA.
• The metal-on-metal articulation may present problems.
• Resurfacing carries a risk of femoral neck fractures.
• Correcting a severe deformity (limb-length discrepancies or offset) may be difficult to accomplish with resurfacing.
• Resurfacing uses press-fit cups (no screws) that are harder to implant.
• Resurfacing requires more soft-tissue dissection than THA.

“I believe that most of these disadvantages make resurfacing less than ideal for the patient with a history of SCFE because the femoral and acetabular structural problems may pose challenges during implantation,” said Dr. Sierra.

He added, “The only published paper looking at the results of hip resurfacing in patients with childhood hip disorders found that nine out of 10 patients continued with what the authors called ‘minor activity-related pain in the groin or the buttocks.’ For me, that is not acceptable and a huge disadvantage of hip resurfacing in this patient population. In addition, if any osteonecrosis of the femoral head was present, you’d have to assess whether or not there was enough viable bone to do the hip resurfacing.”

THA—the better option
In Dr. Sierra’s opinion, THA is the better option for the select patient with advanced degenerative hip disease secondary to SCFE. One reason is the importance of making the anatomy as normal as possible with improved biomechanics in the hip.

“Many of these patients have quite a leg-length discrepancy. THA allows for restoration of unequal leg lengths, especially in the female or young male patient,” he explained.

THA also has the option of using different bearing surfaces, independent of age and gender.

“I tend to limit the use of alternate bearing surfaces,” said Dr. Sierra. “I choose a ceramic-on-ceramic bearing in the ultra-young patient (teens or early 20s) because of the wear benefits, although ceramic breaking and squeaking can occur.”

In women of child-bearing age, Dr. Sierra prefers to use a ceramic- or metal-on-polyethylene implant. Currently, he does not use metal-on-metal designs, citing the significant number of reported problems associated with metal hypersensitivity.

Dr. Sierra also pointed out that good data exist about the outcomes and survivorship of total hip replacements in patients with a history of SCFE, but such data are not available for patients who have had resurfacing procedures.

“I believe that THA provides better functional outcomes with known mid- to long-term survivorship,” he said. “But I would still be cautious about offering it, especially in the extremely young patient.”

Maureen Leahy is assistant managing editor of AAOS Now. She can be reached at leahy@aaos.org

Disclosure information for Dr. Sierra—Biomet Amplitude; Biomet; Arthrex, Inc.; DePuy, A Johnson & Johnson Company; Zimmer; Stryker; American Association of Hip and Knee Surgeons

References:

Amstutz HC, Su EP, Le Duff MJ: Surface arthroplasty in young patients with hip arthritis secondary to childhood disorders. Orthop Clin North Am 2005;36(2),223-230.

Videos
SCFE: Surgical Hip Dislocation for Anatomic Reorientation of Severe SCFE
Slipped Capital Femoral Epiphysis (OKO)

Bottom Line

• A small group of patients treated for SCFE may eventually require arthroplasty to manage end-stage hip arthritis, osteonecrosis, or chondrolysis.
• Resurfacing and THA are surgical treatment options for select patients with advanced degenerative hip disease secondary to SCFE.
• Although hip resurfacing preserves femoral bone, the procedure can be technically challenging in patients with a history of SCFE.
• THA is the better option for the select patient with advanced degenerative hip disease secondary to SCFE.