Introduction
SCFE is defined as the posteroinferior relegation of the proximal femoral epiphysis on metaphysis through the epiphyseal growth plate. SCFE is classified into a stable and an unstable type grounded on the stability of the physis. An unstable SCFE is clinically determined when a child can not bear weight on the affected leg with or without support. It generally has a worse outcomes than a stable SCFE with a advanced rate of complications similar as avascular necrosis (AVN) of the femoral head. The AVN rate for stable SCFE has been reported to be as low as 0 as compared with unstable SCFE ranging between 14 and 50.1 The dependence of treatment includes exertion and life style variations, anti inflammatory drugs and physiotheraphy. When these measures doesn’t show promising measures, surgical intervention is generally indicated. It's estimated that 45% of SCFE cases will suffer a total hip arthroplasty (THA) within 50 years of 1st trauma.2
Case Report
Patient profile
Presenting a case of 25 years male with complaints of pain in both hips and difficulty in walking for 6 years.
Patient started experiencing pain in right hip 6 years prior which gradually progressed and within six months both hips were involved.
Patient developed difficulty in walking due to pain and had to rest intermittent to continue walking. Then he visited a private hospital where he was diagnosed with SCFE and closed reduction with screw fixation was done.
Implant removal was done within 6 months at the same setup.
Patient continued to have pain even after hardware removal and did not receive any treatment for next 6 years.
Patient is currently receiving treatment for endocrinopathy from private clinic.
Currently patient has difficulty in walking, walking up and down the stairs difficulty sitting on chair.
Unable to squat and sit cross legged.
Examination
Procedure
In lateral decubitus position, under complete asepsis incision was taken through posterior approach subcutaneous soft tisse with fat is dissected along same plane.
Tensor fascia latae is cut and retracted, gluteus maximus is split with blunt dissection to expose short external rotators.
Short external rotators are tied, cut and reflected. Joint capsule is cut in inverted T shape. Joint was dislocated.
Once head and neck is visualised, marking was done over the neck to preserve at least 1 cm of calcur. Neck was resected using saw drill.
Adequate exposure of acetabulum was attained using multiple acetabular retractors. Acetabulum was reamed till all the sclerosed margins are cleared and bleeding points are observed.
Uncemented acetabular cup was inserted after trial in adequate anteversion followed by HMWPE liner placement.
Femoral canal is prepared, trail was done.
Uncemented femoral stem with metal head is inserted, joint relocated.
Short rotators are tied to the GT, drain placed and fascia is closed with continuous sutures. Skin closed in layers.
Results
Discussion
Residual deformity of proximal femur after an initial treatment of SCFE causes poorer long-term outcome including pain, limitation of hip ROM, femoroacetabular impingement (FAI) and osteoarthritis.3, 4
Avascular necrosis of the femoral head (AVN) is the most serious complication of SCFE, observed nearly always after unstable slips (up to 47% of the cases). AVN may develop within some time after the slip. Hip pain and limp worsen with time. AVN generally affects the anterosuperior portion of the femoral head. Symptoms complicate with the collapse of the necrotic bone, after which rapid destruction of the joint is ineluctable.5
THA in this unique group of cases is technically grueling because of the abnormal deconstruction of anatomy and multi-planar abnormalities encountered in the proximal femur. Cases witnessing THA for degenerative common complaint secondary to SCFE are significantly younger than those who generally undergo THA for primary OA. It's generally accepted that the more severe the original slip, the sooner the onset of debilitating hip pain and need for arthroplasty surgery. This problem is compounded in cases who develop avascular necrosis of the femoral head.6
Boyle et al.7 in his study found that the average age of cases treated for THA following SCFE was 48.5 years, which was significantly earlier than those with primary OA, whose average age was 67.6 times. 7 In our case patient age was significantly lower i.e. 25 years.
Schoof et al.8 found that the mean leg length difference was set up to have reduced from an normal of13.5 mm preoperatively to 4.5 mm post-operatively. In our case leg length discrepancy post-operatively was lower than that.
The Harris hipsterism score (HHS) enhanced by a mean of 41.3 points post-operatively is reported in multiple studies (34 to 59).9 In our case the enhancement was 60 points which significant with other studies.
Torchia et al.10 demonstrated a high failure rate of cemented THA in younger cases reaching 45 at 15 times postoperatively. TRAINA et al.11 acknowledged use of uncemented prosthesis in 90 percent of their cases with good survival rate of implant and smaller complications. In our case uncemented prosthesis obsession with modular neck was used. Good short term outgrowth is observed.
