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Purpose: The purpose of this review is to discuss the insights into slipped capital femoral epiphysis (SCFE) gained during the last decade, including a proposed rotational pathomechanism, the importance of epiphyseal morphology, subclinical endocrinopathies and atypical SCFE, and updates to current management practices.
Pathophysiology: Growing literature has highlighted the importance of the epiphyseal tubercle as a ‘keystone’ stabilizer of the proximal femoral epiphysis. Both anatomic and clinical studies recently demonstrated that the epiphysis rotates around the epiphyseal tubercle during SCFE. Clinical endocrinopathies contribute to the pathogenesis of SCFE, though recently the effects of subclinical endocrine derangements such as hyperinsulinism and leptin abnormalities have been demonstrated to play a role in SCFE.
Diagnosis: The standard diagnostic tools for SCFE remain the antero-posterior pelvis and frog-leg lateral radiograph. The importance of imaging bilateral hips is well known, due to the increased incidence of contralateral slip development in SCFE patients. Additionally, due to increased knowledge of atypical SCFE, patients with positive age-weight or age-height testing are also recommended to undergo further endocrine workup due to the high likelihood of atypical SCFE in these patients.
Management: In-situ pinning remains the gold standard treatment of SCFE. Use of two-screws is mainly reserved for unstable or severe slips, while one-screw fixation remains the standard for mild-moderate slips. Contralateral prophylactic pinning is typically considered in those patients at high risk for contralateral slip, including those with endocrine risk factors, skeletal immaturity via modified oxford bone age, or aberrant radiographic parameters such as posterior epiphyseal tilt or posterior sloping angle. Novel techniques including intraoperative epiphyseal perfusion monitoring have provided insight into reducing complications such as avascular necrosis and have shown the benefit of intracapsular hematoma decompression for unstable SCFE. Open surgical management via the modified Dunn procedure should be cautiously considered, as high rates of osteonecrosis have been reported due to the vulnerable blood supply of the proximal femoral head.