ORIGINAL ARTICLE
Capsulotomy in Unstable Slipped Capital Femoral
Epiphysis and the Odds of AVN: A Meta-analysis
of Retrospective Studies
Neil Kaushal, MD,* Cynthia Chen, MD,† Kunal N. Agarwal, MS,‡ Tim Schrader, MD,§
Derek Kelly, MD,∥ and Emily R. Dodwell, MD, MPH, FRCSC‡
Background: Unstable slipped capital femoral epiphysis (SCFE)
may lead to avascular necrosis (AVN) in up to 60% of patients.
The aim of this study was to assess the best clinical evidence to
determine the effect of capsular decompression (CD) on odds of
AVN in unstable SCFE.
Methods: Medline, Embase, and Cochrane databases were sys-
tematically searched for comparative studies investigating AVN
rates in unstable SCFE treated with or without CD (aspiration,
percutaneous, or open). Quality was evaluated by the Newcastle
Ottawa Scale. A comparative analysis with pooled effect estimates
using random-effects modeling was calculated. Secondary analysis
pooled AVN rates from both comparative studies and case series.
Results: Comparative analysis included 17 retrospective studies
with 453 hips (201 with CD, 252 without CD). Thirty-four of 201
(17%) hips with CD developed AVN, while 67 of 252 (27%) hips
without CD developed AVN. The odds of AVN for patients
treated with or without CD [odds ratio = 0.80, 95% confidence
interval (CI): 0.48-1.35] was not statistically different. Subanalysis
on patients treated with in situ pinning or positional reduction and
pinning showed no difference in AVN rates with or without CD
(odds ratio = 0.97, 95% CI: 0.44-2.10). In the secondary analysis of
17 comparative studies and 23 case series, the average rate of AVN
was 17%, 0.17 (95% CI: 0.13-0.23) for patients treated with CD
(60/447 hips) and 28%, 0.28 (95% CI: 0.22-0.35) for patients treated
without CD (129/464 hips).
Conclusions: There was no statistically significant decrease in odds of
AVN with CD. However, studies were limited by their retrospective
nature and inadequate documentation of CD techniques; the majority
From the *Rutgers-New Jersey Medical School, Newark, NJ;
†New York Presbyterian, Columbia University Irving Medical Cen-
ter; ‡Hospital for Special Surgery, New York, NY; §Children’s
Healthcare of Atlanta, CPG—Orthopaedics, Atlanta, GA; and
∥Campbell Clinic Orthopedics and University of Tennessee Depart-
ment of Orthopedics and Biomechanics, Collierville, TN.
No source of funding.
The authors declare no conflicts of interest.
Reprints: Emily R. Dodwell, MD, MPH, FRCSC, Hospital for Special
Surgery, 535 East 70th Street, New York, NY 10021.
E-mail: dodwelle@hss.edu.
Supplemental Digital Content is available for this article. Direct URL
citations appear in the printed text and are provided in the HTML
and PDF versions of this article on the journal’s website, www.
pedorthopaedics.com.
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/BPO.0000000000001359
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lacked femoral head blood flow monitoring to demonstrate adequate
decompression. Future prospective studies with carefully documented
complete decompression may help to elucidate the effect of CD on
AVN risk. Although there was no statistically different odds of AVN
with or without CD, even this large meta-analysis was underpowered,
and one cannot conclude that there was truly no difference in odds of
AVN without an appropriately powered study. Therefore, we rec-
ommend routine CD for all unstable SCFEs pending additional re-
search, as CD adds little to the surgical procedure and may minimize
the risk of a devastating insult to the femoral head.
Key Words: capsulotomy, hip decompression, AVN, unstable
SCFE
(J Pediatr Orthop 2019;39:e406–411)
A vascular necrosis (AVN) of the femoral head is one of
the most devastating outcomes of unstable slipped
capital femoral epiphysis (SCFE). Loder initially defined
an unstable SCFE as one in which the patient is unable to
ambulate secondary to pain, even with crutches.1 Multiple
studies have demonstrated that unstable SCFE has a sig-
nificantly higher risk of AVN than stable slips,1–3 with
AVN rates as high as 60% in some series. The exact eti-
ology is of AVN in unstable SCFE has not been eluci-
dated; however, multiple possible mechanisms have been
proposed. These include frank vascular laceration of the
lateral ascending branch of the medial femoral circumflex
artery; vascular kinking, spasm, and thrombosis due to
infolding of the posterior soft tissue envelope following
epiphyseal displacement; and vascular tamponade due to
increased intracapsular pressure beyond the perfusion
pressure of the femoral head vascular supply.4,5 With
complete vascular disruption/laceration there is little po-
tential for surgical intervention to re-establish perfusion.
However, when decreased femoral head perfusion is due
to tamponade, capsular release could potentially relieve
the excessive pressure on the vessels, thus making intra-
capsular pressure tamponade a potentially reversible cause
of AVN in the setting of unstable SCFE.
The role of increased intracapsular pressure in the
development of AVN in unstable SCFE remains unclear
although a recent prospective series with precapsulotomy
and postcapsulotomy vascular flow measurements suggests
J Pediatr Orthop  Volume 39, Number 6, July 2019
J Pediatr Orthop  Volume 39, Number 6, July 2019
that capsulotomy with confirmed return of blood flow to the
femoral head entirely removes the risk of AVN.6 The aim of
this meta-analysis was to assess the best clinical evidence to
determine the effect of capsular decompression (CD) on
odds of AVN in unstable SCFE.
METHODS
MEDLINE, EMBASE, and COCHRANE databases
were systematically searched without language restrictions.
Maximally expanded search terms for unstable SCFE, intra-
capsular hemorrhage/hematoma, decompression, and AVN
with Boolean operators were employed (see Appendix A,
Supplemental Digital Content 1, http://links.lww.com/BPO/
A216, for complete search strategy). The hospital’s senior
medical librarian assisted with the search strategy development
and execution. The period searched was 1967 to October 2016
inclusive. Two reviewers independently assessed each title for
inclusion (C.C., N.K.), and relevant abstracts were in-
dependently evaluated. If doubt existed regarding relevance,
the full text article was assessed. Articles of interest were those
whose subjects had unstable SCFE, whose outcome of interest
was AVN. In the comparative analysis [calculation of odds
ratio (OR)] studies had to include an arm with unstable SCFEs
that underwent decompression and those who did not.
Randomized trials, cohort and case-control studies were eli-
gible for inclusion in the comparative pooled analysis. In ad-
dition to the comparative analysis, a secondary analysis was
performed including both comparative studies, as well as case
series that reported on groups of patients in which either all or
none underwent decompression. In this larger scale pooled
analysis to determine AVN rates for unstable SCFE with and
without decompression randomized trials, cohort, case-control,
and case series were eligible for inclusion. Case reports, reviews,
letters and editorial comments, and all other publications were
excluded.
Study quality assessment was performed in duplicate
by 2 independent reviewers (C.C., N.K.) using the New-
castle Ottawa Scale (NOS) recommended by the Cochrane
Collaboration for assessing the quality of nonrandomized
studies.7 Any conflicts were resolved by a third in-
dependent reviewer (E.D.). Studies with a quality score of
5 or greater on the 9-point NOS were considered appro-
priate for inclusion. There were no language restrictions.
Foreign studies were translated with Google translate and
confirmed for exclusion or inclusion with the assistance of
a medically knowledgeable native speaker of the language.
The summary of study flow is provided (Fig. 1).
Three reviewers (C.C., N.K., K.N.A.) extracted rele-
vant information including presence and type of reduction,
method of SCFE treatment, method of capsulotomies, and
rate of AVN. Demographic information such as mean age
at operation, and follow-up information was also extracted.
All data were analyzed using Comprehensive Meta-
Analysis software CMA V2 (Biostat, Englewood, NJ). In the
comparative analysis, pooled risk estimates were obtained us-
ing a random-effects model by the methods of DerSimonian
and Laird with inverse-variance weighting. A random-effects
model was used, as this was more statistically conservative
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Capsulotomy in Unstable SCFE
even though heterogeneity between studies was low. As there
were no studies that presented an adjusted OR, raw data for
AVN events and nonevents among subjects with and without
decompression were used to calculate crude OR for each
study. If raw data were unavailable, then the crude OR from
the study was used. In addition, in the secondary analysis to
determined weighted averages of AVN rate with and without
capsulotomy, these were obtained using a random-effects
model. In order to be pooled, the articles must have reported
the number of AVN events and the total number of hips
undergoing the procedure. Cochrane Q and I2 statistics were
calculated to assess heterogeneity between studies.
Study quality was identified a priori, as a potential
source of heterogeneity. Metaregression was used to evaluate
the effect size of the odds of AVN as a function of study
quality. Publication bias was assessed by funnel plot, Eggers
regression analysis, and Kendall τ test with a level of sig-
nificance of 0.05. This meta-analysis was performed and re-
ported in accordance with Preferred Reporting Items for
Systemic reviews and Meta-Analyses (PRISMA) guidelines.8
Risk of bias within individual studies was evaluated using the
NOS for quality. Results are reported as ORs with 95%
confidence intervals (95% CIs), with a level of significance set
at 0.05. In secondary analysis involving case series, AVN
rates were reported as percentage of AVN cases treated with
CD or without CD with 95% CIs.
RESULTS
Seventeen retrospective studies were eligible for in-
clusion in the comparative analysis (Table 1).1,2,5,6,9–21
Forty retrospective studies (17 comparative and 23 case
series) were eligible for inclusion in the secondary analysis to
determine AVN rates. Extracted data are provided in
Table 1. No evidence of publication bias was identified on
Kendall τ test, Egger regression, or funnel plot (Fig. 2).
A total of 453 unstable SCFE hips, treated with or
without hip decompression were included in the comparative
analysis. Of the 201 unstable SCFE whose treatment included
a capsulotomy, 34 developed AVN (17%); of the 252 unstable
SCFE whose treatment did not include a capsulotomy, 67
developed AVN (27%). The odds of AVN for patients treated
with CD versus no CD (OR = 0.80, 95% CI: 0.48-1.35) was
not statistically significant (Fig. 3). Subanalysis including
children treated with in situ pinning or positional reduction
and pinning (excluding patients who underwent osteotomy or
other procedure at time of pinning) showed no difference in
odds of AVN with or without CD (OR = 0.97, 95% CI: 0.44-
2.10) (Table 2). Subanalysis regarding children who were
treated with bony procedures (Modified Dunn, subcapital
cuneiform osteotomy, open bone block epiphysiodesis) showed
no difference in odds of AVN with or without CD (OR = 0.71,
95% CI: 0.34-1.47) (Table 2).
In the secondary analysis to determine overall AVN
rates with and without capsulotomy, 911 hips were included.
A total of 464 hips did not undergo decompression of which
129 developed AVN [AVN rate of 28%, 0.28 (95% CI: 22%-
35%)] and 447 hips underwent decompression of which 60
developed AVN [AVN rate of 17%, 0.17 (95% CI: 13%-23%)].
www.pedorthopaedics.com | e407
Kaushal et al
FIGURE 1. PRISMA diagram showing flow of study inclusion. AVN indicates avascular necrosis.
Follow-up ranged from 6 months to 18 years. Two
studies did not state their follow-up period.12,18 Four studies
included only subjects with at least 2 years of follow-
up.2,10,19,22 Study quality, which included an assessment of
bias, was graded by the NOS scale and is presented (Table 1).
Metaregression on quality of the study revealed no significant
association between quality and the effect size for the odds of
AVN (P > 0.05).
DISCUSSION
The aim of this study was to assess the best available
evidence regarding the effect of CD on the odds of AVN in the
treatment of unstable SCFE. Despite the literature suggesting
the potential benefit of CD, our meta-analysis did not dem-
onstrate a statistically significant decrease in odds of AVN in
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J Pediatr Orthop  Volume 39, Number 6, July 2019
unstable slips undergoing a CD. This trend continued even as
we broke down the capsulotomy group into hips that had a
positional reduction and pining followed by decompression
and those hips that were decompressed through more
invasive bony procedures. Our pooled analysis of all
studies1–3,5,6,9–12,14–21,23–44 demonstrated 11% higher rate of
AVN in unstable slips treated without CD, but we cannot
make any statistical conclusions as these papers were not eli-
gible to be included in our comparative study.
This meta-analysis has a number of limitations. The
majority of the literature included in the meta-analysis was
retrospective in nature; therefore misclassification and other
forms of bias may be present. Furthermore, the sample size
required to show a statistically significant difference between
17% and 27% is 269 patients per arm, thus our comparative
meta-analysis is underpowered to show this difference.
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J Pediatr Orthop  Volume 39, Number 6, July 2019 Capsulotomy in Unstable SCFE

TABLE 1. Characteristics of Studies Included in the Meta-Analysis of Avascular Necrosis in Unstable Slipped Capital Femoral
Epiphysis
Total Unstable Hips With #AVN in Total # Mean Age Type of Capsular
References Design SCFE Decompression Decompressed Hips AVN (y) Decompression
Alves et al17 Retrospective 12 6 4 6 12.2 Open
cohort
Aronson Retrospective 12 7 0 2 — Open
et al18 cohort
Chen et al19 Retrospective 30 21 3 4 11.6 Open, percutaneous
cohort
Gordon et al21 Retrospective 16 10 1 2 11.1 Open, percutaneous
cohort
Kennedy Retrospective 27 9 2 4 11.3 Open
et al2 cohort
Peterson Retrospective 91 46 6 13 — Open
et al11 cohort
Phillips et al12 Retrospective 14 3 0 0 13 Open
cohort
Sankar et al13 Retrospective 70 31 5 14 12.6 Open and percutaneous
cohort
Loder et al1 Retrospective 30 2 1 14 12 Open
cohort
Herrera-Soto Retrospective 14 11 0 0 11.4 Aspiration or
et al5 cohort percutaneous
Kitano et al10 Retrospective 21 7 1 7 11.7 Arthrocentesis
cohort
Cosma et al20 Retrospective 5 1 0 0 13 Open
cohort (median)
Alshryda Retrospective 22 15 4 7 13.4 Open
et al16 cohort
Walton et al15 Retrospective 46 16 4 15 12.6 Open
cohort
Souder et al14 Retrospective 14 8 3 5 — Open, percutaneous
cohort
Schrader et al6 Prospective 13 6 0 0 13 Aspiration, percutaneous
cohort
Kalogrianitis Retrospective 16 2 0 8 12.5 Open
et al9 cohort
AVN indicates avascular necrosis.

Another major limitation was the lack of detail regarding
the type and quality of CDs performed. CDs included per-
cutaneous needle decompression, percutaneous release, and
open procedures including osteotomies. The variety in
quality and accuracy of these methods adds an additional
variable influencing the potential effect of decompression on
odds of hips developing AVN. Only one article6 docu-
mented adequacy of the compression with intraoperative
perfusion monitoring, and this study had no reported cases
of AVN at 2-year follow-up for unstable SCFE.

FIGURE 2. Funnel plot showing no evidence of publication bias.

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Kaushal et al J Pediatr Orthop  Volume 39, Number 6, July 2019

FIGURE 3. Forrest plot showing that odds of AVN after capulotomy versus no capsulotomy are not significant Odds ratio = 0.80,
95% CI: 0.48-1.35. AVN indicates avascular necrosis; CI, confidence interval.

Herrera-Soto et al22 demonstrated in a series of unstable
SCFE that intracapsular pressures often simulated a com-
partment syndrome-like phenomenon in the joint capsule.
Postcapsulotomy pressures in this series were significantly less
than predecompression readings. Gordon et al21 reported on
10 unstable SCFE that underwent either a percutaneous
capsulotomy or an arthrotomy and open reduction, with only
one hip developing AVN. Sankar et al13 reviewed their series
of unstable SCFE and reported an AVN rate of 16% in hips
that underwent a CD, while reporting a 23% AVN rate in
hips that did not have a capsulotomy. A prior meta-analysis45
on this topic included 9 studies documenting capsulotomy in
unstable SCFE. Our meta-analysis included 17 studies that
documented CD in unstable SCFE, and also included a sec-
ondary analysis of 40 retrospective studies that were not
necessarily included in the formal comparative study.
Future prospective studies and more series that docu-
ment a quality capsulotomy with possible intraoperative
femoral head perfusion monitoring may help to elucidate the
potential affect that relieving intracapsular pressure may have
on AVN rates in unstable SCFE. Improved knowledge of risk
factors for AVN and the role of hip decompression techniques
may optimize our approach to the unstable SCFE. On the
basis of our findings from this meta-analysis, we cannot
confirm that CD lowers the rate of AVN following unstable
SCFE; therefore, the surgeon must weigh the minor risks of
this added procedure against the lack of conclusive evidence
showing a lower AVN rate. The single study that documented
femoral head epiphyseal perfusion precapsulotomy and
postcapsulotomy found no cases of AVN following restora-
tion of flow. Further prospective studies with carefully docu-
mented complete capsulotomy may help to elucidate the effect
of hip decompression on perfusion to the femoral head and
AVN risk in the treatment of unstable SCFE. Although there
was no statistically different odds of AVN with or without
CD, even this large meta-analysis was underpowered, and one
cannot conclude that there was truly no difference in odds of
AVN without an appropriately powered study. Therefore, we
recommend routine CD for all unstable SCFEs pending ad-
ditional research, as CD adds little to the surgical procedure

TABLE 2. Pooled Estimates of the Analysis of the Risk of AVN in Unstable SCFE With or Without Capsular Decompression
Odds Lower Upper
Analysis No. Studies Ratio Limit Limit P I2 Statistic Publication Bias
Initial analysis 17 0.80 0.48 1.35 0.408 0 No
Subanalysis: unstable SCFE treated with in situ pinning 9 0.96 0.44 2.1 0.928 0 —
or positional reduction and pinning
Subanalysis: unstable SCFE treated with bony procedure 5 0.71 0.34 1.47 0.353 0 —
AVN indicates avascular necrosis; SCFE, slipped capital femoral epiphysis.

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J Pediatr Orthop  Volume 39, Number 6, July 2019
and may minimize the risk of a devastating insult to the
femoral head.
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