Journal of Orthopaedic Science 23 (2018) 220e228

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Journal of Orthopaedic Science

journal homepage: http://www.elsevier.com/locate/jos

Instructional Lecture

Diagnosis and treatment of slipped capital femoral epiphysis: Recent

trends to note*
Takuya Otani*, Yasuhiko Kawaguchi, Keishi Marumo
Department of Orthopaedic Surgery, The Jikei University School of Medicine, Japan

a r t i c l e i n f o a b s t r a c t

Article history: Slipped capital femoral epiphysis (SCFE) is not frequently encountered during routine practice and
Received 24 October 2017 diagnosis and treatment are often delayed. It is important to understand symptoms and imaging features
Received in revised form to avoid delayed diagnosis. After the diagnosis is made correct classification of the disease is required.
18 December 2017
The classification should be based on the physeal stability in order to choose safe and effective treatment.
Accepted 20 December 2017
Available online 1 February 2018
However, surgeons should bear in mind that the assessment is challenging and actual physeal stability is
not always consistent with the stability predicted by a clinical classification method.
Treatment of stable SCFE: Closed reduction is not indicated for stable SCFE, where continuity between the
epiphysis and metaphysis has not been disrupted. Treatment method(s) is (are) chosen from in-situ
fixation, osteotomy and femoroacetabular impingement treatment. A single screw fixation is often used
to fix the epiphysis and the dynamic method is considered especially for young patients. Traditional
three-dimensional trochanteric osteotomies have been associated with procedural complexity and un-
certainty. A simpler osteotomy method using an updated imaging analysis technology should be
considered. Modified-Dunn procedure is indicated for a severe stable SCFE. However, caution is required
because recent studies have reported a high rate of complications including postoperative femoral head
avascular necrosis (AVN) and hip instability when this method is indicated for stable SCFE.
Treatment of unstable SCFE: Treatment of unstable SCFE is difficult and complication rate is high. Most of
unstable SCFE patients were previously treated with closed method and it was difficult to predict an
occurrence of postoperative AVN. However, treatment of unstable SCFE has gradually changed in recent
years and many studies have shown that physeal hemodynamics can be assessed during treatment.
Preoperative assessments include contrast-enhanced MRI and bone scintigraphy. Intraoperative assess-
ments include confirmation of bleeding after drilling the femoral head and monitoring the intracranial
pressure by laser doppler flowmetry. It is expected that postoperative AVN can be prevented in many
cases by performing the treatment while assessing the intraoperative physeal hemodynamics. Open
surgeries have begun to be indicated in the treatment of unstable SCFE through either of anterior
approach or (modified) Dunn procedure. The authors expect that recent improvements in assessment of
physeal hemodynamics and open treatment method provide improved clinical outcomes in the treat-
ment of SCFE.
© 2018 The Japanese Orthopaedic Association. Published by Elsevier B.V. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction metaphysis. This condition is not frequently encountered during

Slipped capital femoral epiphysis (SCFE) is a hip disorder that
occurs in school children during the period of active growth be-
tween the ages of 10 and 13 years. SCFE results in posterior
displacement of the proximal femoral epiphysis in relation to the
*
This Instructional lecture was presented at the 90th Annual Meeting of the
Japanese Orthopaedic Association, Sendai, May 18, 2017.
* Corresponding author. Department of Orthopaedic Surgery, The Jikei University
DAISAN Hospital, 4-11-1 Izumi-Honcho, Komae-shi, Tokyo, 201-8601, Japan. Fax:
þ81 3 3480 5700.
E-mail address: t-otani@jikei.ac.jp (T. Otani).
routine practice, and diagnosis is sometimes challenging during the
early stages of the disease, so diagnosis and treatment are often
delayed. There are also various treatment methods based on dis-
ease type and severity, yet no comprehensive consensus on treat-
ment method selection has been achieved; thus, treatment of this
condition is challenging. Furthermore, new reports are constantly
emerging about the pathology and treatment of this disease, and so
it is important to strive to obtain the most current information. This
paper discusses the epidemiology, diagnosis, and treatment of
SCFE, with explanations of factors that need to be understood
regarding current diagnosis and treatment.

https://doi.org/10.1016/j.jos.2017.12.009
0949-2658/© 2018 The Japanese Orthopaedic Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.
org/licenses/by-nc-nd/4.0/).
 T. Otani et al. / Journal of Orthopaedic Science 23 (2018) 220e228
Table 1
Important points for diagnosing SCFE.
Symptoms and physical findings
1) Chief complaints include pain/discomfort around the hips, thighs and knees,
and limping.
2) Not all patients complain of severe pain.
3) Complaints of localized knee symptoms only, frequently cause delayed
diagnosis or misdiagnosis.
4) ROM of hip and knee joints on both sides must be compared with the patient
in a supine position.
5) Drehmann's sign, which is passive abduction and external rotation of the hip
on hip flexion, is typically positive.
Diagnostic imaging
1) Frontal and lateral imaging of both hips must be performed to compare the
findings on either side.
2) A suitable method for lateral projection should be selected to visualize the
area from the femoral head to the neck.
3) Frontal and lateral radiographs can be examined for the presence of
widening and irregularity of the physeal line.
4) Frontal views should be examined for reduced physeal height and the
presence of Trethowan's sign.
5) Posterior tilt angles, measured on lateral views, should be compared
between both sides.
6) MRI is suitable for early diagnosis and for evaluating the preslip state in the
contralateral side.
SCFE, slipped capital femoral epiphysis; ROM, range of motion; MRI, magnetic
resonance imaging.
1.1. Epidemiology: the increasing incidence of SCFE in Japan, and
obesity and sporting activities as factors related to onset
In 1976, Ninomiya et al. [1] reported that the incidence of SCFE
in Japan was 0.3e0.5 for boys per 100,000 boys aged 10e14 years
and 0.05 to 0.08 for girls per 100,000 girls aged 10e14 years (total
yearly incidence: 0.2e0.3 per 100,000 children aged 10e14 years).
Subsequently, the Japanese Pediatric Orthopedic Association (JPOA)
surveyed the incidence from 1997 to 1999, and a 2002 paper by
Noguchi et al. [2] reported an incidence of 2.22 and 0.76 for boys
and girls, respectively, per 100,000 children aged 10e14 years.
Specifically, SCFE incidence appears to be increasing rapidly in
Japan, with a 5-fold increase among boys and 10-fold increase
among girls over an approximately 20-year period spanning the
1970s and 1990s. Therefore, the actual incidence in recent years
might be even greater. Hence, these results should be viewed with
caution. Noguchi et al. reported a frequency of onset of bilateral
SCFE of 14% [2], which is low compared with reports of 18%e50% in
Western countries. The time until onset on the contralateral side
ranges from 0 to 33 (mean, 10) months, and onset usually occurs
within 24 months in most patients. This means that patients should
be carefully followed up for contralateral onset for at least 2 years
after onset on the original side.
Hip joint morphology is a major factor related to onset. Joints in
which the epiphysis is frequently subjected to posterior shearing
forces, joints with retroversion or minimal anteversion of the
femoral neck, joints with posterior tilt of the physeal line, joints
with retroversion of the acetabulum, and joints with large lateral
covering are examples of hip joint morphology that favor the onset
of SCFE [3,4]. The mechanical environment surrounding the hip
joint is another important factor related to onset, and obesity and
sporting activity are significant in this regard. Reports from West-
ern countries suggest that the age at SCFE onset appears to be
decreasing, and obesity appears to be strongly related to onset in
young patients [5,6]. Seasonal variation of onset has also been
observed, and reports indicate that onset is more likely during
periods when children are the most engaged in sporting activities.
In addition, hormonal imbalance has been identified as a factor that
induces slippage, although we do not frequently encounter cases
exhibiting obvious endocrine dysfunction in our clinical practice.
221
1.2. Diagnosis: understanding symptoms and imaging features
contribute to preventing delayed diagnosis
A diagnosis of SCFE is based on symptoms and results of imaging
investigations (Table 1). The primary symptoms are pain and a
limping gait. Diagnosis is frequently delayed when encountering
patients who do not necessarily report severe pain or who
complain of pain around the knee rather than the hip joint.
Restricted range of motion (ROM) in the hip joint is an important
finding during physical examination, and flexion and internal
rotation are frequently restricted. A well-known diagnostic finding
is the Drehmann's sign, which refers to abduction and external
rotation of the hip joint in response to passive flexion. In order to
avoid missing a diagnosis of SCFE, it is important to always perform
thorough physical examination of patients who complain of
symptoms around the hip joint, thigh, or knee joint in a supine
position, and to compare the mobility of the hip and knee joints on
either side.
The first method of diagnostic imaging used for evaluation is
plain radiography performed appropriately and systematically.
Bidirectional imaging of both sides must be performed to compare
the findings on either side. The Lauenstein projection is an estab-
lished lateral view, and although this projection is suitable for ex-
amination of the femoral diaphysis, due to overlap, it does not
enable clear examination of the area from the femoral head to the
femoral neck. Thus, other methods are preferred, such as the Dunn
view or modified Dunlap lateral view, which involve reducing
abduction by elevating the femur, and generating comprehensible
views of the area from the femoral head to the femoral neck (Fig. 1).
For patients with unstable SCFE who have severe pain, the cross-
table lateral view is useful for imaging the hip in a neutral posi-
tion. Frontal and lateral views can be examined for the presence of
widening and irregularity of the physeal line. Frontal views should
be examined for reduced physeal height and the presence of Tre-
thowan's sign. Trethowan's sign is positive when Klein's line, a line
extending along the superior surface of the femoral neck, does not
transect the physeal region. Lateral views are used to measure the
posterior tilt angle that represents the inclination of the epiphysis
relative to the axis of the proximal femoral diaphysis, and compare
findings on either side (Fig. 2). Magnetic resonance imaging (MRI)
is suitable for diagnosing the early stage of the slip or evaluating the
preslip state if the patient is asymptomatic but at risk of slippage in
the contralateral hip joint. Computed tomography (CT) and three-
dimensional (3D)-CT are used for 3D morphological evaluation,
surgical planning, and postoperative evaluation, rather than for
diagnosis.
Understanding the above-mentioned diagnostic modalities may
help reduce the number of patients affected by delayed diagnosis.
According to a 2016 paper by Schur et al. [7], the period from
symptomatic onset until diagnosis in 481 patients diagnosed with
SCFE from 2003 to 2012 was 0e169 days (mean, 17 weeks). There
was no tendency towards improvement over the 10-year study
period, and SCFE diagnosis continues to be delayed. In addition, the
initial medical examination of the majority of SCFE patients was
performed by the primary care provider or at the emergency
department. The diagnosis was significantly delayed in these cases,
as compared with patients who were initially examined at an or-
thopedic clinic, so it is important to provide such facilities with
education and awareness initiatives.
1.3. Disease classification: safe and effective treatment is associated
with correct evaluation and classification
The most common form of SCFE classification was traditionally
based on the amount of time that has elapsed since onset. Acute
222 T. Otani et al. / Journal of Orthopaedic Science 23 (2018) 220e228

Fig. 1. Lateral projection of the hip joint. a. The Lauenstein projection is suitable for examination of the femoral diaphysis but not for examination of the area extending from the
femoral head to the neck due to overlap. b. Reduction of abduction by elevating the femur allows clearer viewing of the area from the femoral head to the neck.

Fig. 2. Investigation of the plain radiograph. Bidirectional imaging of both hips must be performed to compare the findings on either side. The presence of widening and irregularity
of the physeal line is examined. a. Frontal views should be examined for reduced physeal height and the presence of Trethowan's sign. b. & c) Lateral views are used to measure the
posterior tilt angle (PTA) and compare findings on either side.

SCFE refers to a period of <3 weeks after onset, chronic SCFE refers
to a continuing course lasting 3 weeks after onset, and acute-on-
chronic SCFE refers to an acute exacerbation that occurs after a
chronic course lasting 3 weeks. The method of treatment was also
selected based on the temporal course, and closed reduction was
indicated for patients with acute SCFE. However, in 1993, Loder
et al. [8] proposed a classification based on the stability of the
physis instead of the temporal course. This classification was simple
and based on clinical symptoms. In this classification, the stable
type refers to cases in which weight bearing and walking are
possible, and the unstable type refers to cases in which these are
not possible, with or without crutches. This classification, which is
based on physeal stability, is reasonable. However, in the man-
agement of SCFE, surgeons should bear in mind that the actual
physeal stability is not always consistent with the stability pre-
dicted by this classification method. Ziebarth et al. [9] investigated
whether the preoperative Loder classification of physeal stability
was consistent with macroscopic findings in 82 patients with SCFE.
The patients had been treated with an open method and it was
determined whether physeal continuity was disrupted. Results
showed that the Loder classification has a sensitivity of 39% and a
specificity of 76%. The above findings show that an actual diagnosis
 T. Otani et al. / Journal of Orthopaedic Science 23 (2018) 220e228 223

of physeal stability is challenging, and treatment methods must be 1.4.2. Osteotomy

selected on a case-by-case basis. Specifically, it is important to
make a comprehensive and careful evaluation of the physeal sta-
bility based on clinical course, plain radiographic images, fluoro-
scopic examinations, and MRI findings including hematoma
volume.
Several methods of osteotomy have been reported to improve
physeal alignment. The Southwick and Imha €user procedures
are well-known traditional trochanteric 3D osteotomies (Fig. 4-A),
although some studies have documented their procedural
complexity and uncertainty. The authors have reported a simpler

1.4. Treatment of stable SCFE: appropriately selecting and

combining in-situ fixation, osteotomy, and femoroacetabular
impingement (FAI) treatment

Closed reduction is not indicated for cases of stable SCFE, where

continuity between the epiphysis and metaphysis has not been
disrupted. Attempted reduction may fail and there is the risk of
inadvertent iatrogenic physeal destabilization, and so the proced-
ure is contraindicated. The appropriate treatment strategy involves
correct selection and combination of in-situ fixation to prevent
progression of current slippage, osteotomy to improve the position
of the epiphysis in relation to the acetabulum, and treatment of FAI,
which is caused by deformity arising in the physealemetaphyseal
transition.

1.4.1. In-situ fixation

Studies have reported favorable long-term outcomes after in-
situ fixation and favorable remodeling of deformities between the
femoral head and neck, and thus there was a move to expand the
indications to include severe cases. However, the pathology of FAI,
which is caused by a deformity of the head-neck region, is gradually
becoming better understood. Follow-up studies of SCFE patients
have also reported injuries to the articular labrum and cartilage due
to FAI [10,11]. Therefore, in recent years, a relatively limited number
of patients with a large slip angle tend to be treated with in-situ
fixation alone. In-situ fixation is performed using one or two
screws, although using two screws increases procedural difficulty
and risk of complications with small concomitant increase in fix-
ation strength. This is why single-screw fixation is usually per-
formed. A dynamic method of fixation [12] that allows growth of
the femoral head and neck and prevents early closure of the physis
is considered in young patients who are expected to have consid-
erable periods of growth before eventual physeal closure (Fig. 3). A
recent study reports that preventing early closure of the physis and
maintaining growth of the femoral neck is associated with favor- Fig. 4. Levels of the femoral osteotomies. A: Trochanteric osteotomy. B: Osteotomy at
able remodeling in this region [13]. the base of the femoral neck. C: Osteotomy performed directly on the site of slippage.

Fig. 3. Dynamic method of screw fixation. a. A short thread screw was used so that the threaded portion was placed within the epiphysis. b. Care was taken to insert the screw
perpendicular to the physis three-dimensionally and the lateral end of the screw was left protruding from the lateral cortex. c. Follow-up radiograph taken three years after surgery.
The protruding lateral screw was gradually drawn into the femur as the patient grew without any signs of premature physeal closure.
224 T. Otani et al. / Journal of Orthopaedic Science 23 (2018) 220e228

and more accurate 3D osteotomy method using an updated imaging
analysis technology [14]. Specifically, CT images that include the
entire length of the femur are generated preoperatively and used to
perform an accurate flexion osteotomy simulation that eliminates
measurement errors by placing the lower limbs in external rotation.
This information is used to calculate the degree of varus or valgus
that should be added to the flexion osteotomy, which is then
incorporated into the operation (Figs. 5e7). Next, we proceed to
osteotomies at the base of the femoral neck (Fig. 4-B), which include
the Kramer and Sugioka procedures. Reports indicate that combined
surgery, which incorporates a modified Kramer procedure and
Sugioka procedure, has been performed in severe cases. Osteoto-
mies performed directly on the site of slippage (Fig. 4-C) include the
Fish procedure, which is an anterior wedge osteotomy performed
through an anterior approach; the Dunn procedure [15], which is
performed with a wide exposure using a trochanteric osteotomy and
allows for protecting the physeal vessels present in the posterior
surface of the femoral neck; and the modified Dunn procedure [16],
which performs the Dunn procedure after surgical dislocation of the
epiphysis from the acetabulum. The modified Dunn procedure has
been the subject of an increasing numbers of reports in recent years,
and will be mentioned in a later section.
1.4.3. Selecting a method of treatment and management of FAI
Treatment of stable SCFE involves determining whether to
perform re-alignment, based on the degree of slippage, and inves-
tigating the need for FAI treatment. Traditionally, in selecting re-
alignment procedures, in-situ fixation is chosen for mild slips,

Fig. 5. Case 1: 13-year-old girl with right stable-type SCFE. a. Frontal view of the hips. b. Lateral view of the affected right hip. Preoperative PTA was 62 .

Fig. 6. CT examination of Case 1. a. CT images covering the entire length of the femur were generated and examined in order to eliminate measurement errors caused by the
external rotation of the femur. b. Correct sagittal view of the femur reconstructed, and precise PTA measured by the proximal femoral axis and the posterior inclination of the physis.
The frontal view of the femoral head was then reconstructed with an inclination of the imaging slice by the degree of flexion osteotomy of 45 . c. Frontal view of the femoral head
reconstructed with an inclination of the imaging slice by the degree of flexion osteotomy (45 ) with the predicted appearance of the femoral head after flexion osteotomy. The varus
inclination of the physis was measured on this image as 25 . If this varus inclination of the physis extends beyond 20e30 , additional varus or valgus correction is planned.
 T. Otani et al. / Journal of Orthopaedic Science 23 (2018) 220e228 225

Fig. 7. Postoperative radiographs of Case 1 (frontal and lateral views). a. Frontal view showing simple flexion osteotomy with a correction angle of 45 performed without additional
varus/valgus correction because the predicted varus inclination of the physis was in the range of 20e30 . Note the appearance of the femoral head including varus inclination of the
physis on the postoperative radiograph (Fig. 7-a) closely resembles that of the predicted CT image (Fig. 6-c). b. Lateral view showing dynamic single screw fixation of the epiphysis
also performed with flexion osteotomy. Postoperative PTA was reduced to 14 . However, note the protruding anterior portion of the metaphysis, which could cause FAI. The
significance of FAI is assessed and followed clinically and radiographically, and anterior bumpectomy is performed if necessary together with removal of the plate and screw after
closure of the physis.

trochanteric osteotomy for moderate slips, and osteotomy at the base
of the femoral neck or area of slippage for severe slips. However, the
range of indications for in-situ fixation has been expanded in recent
years. The options for FAI treatment involve simultaneous FAI
treatment with in-situ fixation or osteotomy during the initial
treatment period, or a second-stage FAI treatment after remodeling
of the femoral neck and clinical symptoms of FAI have been well
evaluated. The authors' treatment strategies for stable SCFE involve
performing in-situ single-screw dynamic fixation for mild to mod-
erate cases, and performing a trochanteric 3D osteotomy based on
the above-mentioned flexion osteotomy to treat moderate to severe
SCFE. Single-screw dynamic fixation of the epiphysis is also per-
formed during the 3D osteotomy (Fig. 7). During the follow-up period
development of FAI is carefully evaluated clinically and radiograph-
ically and, after closure of the physis, open treatment of FAI is per-
formed if necessary concomitant with the hardware removal.
1.5. Treatment of unstable SCFE: poor prognosis, specialist
knowledge required for treatment, and the wealth of information
obtained in recent years
Unstable SCFE is usually difficult to treat, the rate of complica-
tions is high, and treatment outcomes are unfavorable. Also, no
consensus has been reached regarding methods of treatment and
the topic is controversial. This is because the epiphysis separates
from the metaphysis in unstable SCFE, causing the vessels supply-
ing the epiphysis to rupture, kink, and stretch. This in turn poses the
risk of avascular necrosis (AVN) of the femoral head. There is no
definitive and established method for stabilizing the epiphysis that
also prevents this risk. Some surgeons believed in-situ fixation was
safe and others believed gentle reduction and fixation was
reasonable. However, both modalities were theoretical and were
not based on practical evaluation of physeal hemodynamics. Dis-
cussion usually failed to reach a consensus. In Japan, a question-
naire survey conducted in 2009 revealed that in-situ fixation was
selected in 52% of surgeons, and closed gentle reduction and fixa-
tion was selected in 48%; none of the surgeons adopted any other
procedure [17]. However, it is pertinent to note that the treatment
of unstable SCFE has gradually changed as a result of the vast
amount of knowledge gained during recent years. Questionnaire
results obtained in Japan in 2015 demonstrate that in-situ fixation
was selected in 52% of surgeons, a percentage that has remained
unchanged since 2009. However, the surgeons who selected closed
gentle reduction and fixation decreased to 38%, but new options
that were not present in 2009, such as open treatment and the
modified Dunn procedure, accounted for 3% and 7%, respectively, in
2015 [17].
1.5.1. Timing of surgery for unstable SCFE
Previously, we believed that it was important to perform early
reduction and stabilization to prevent AVN of the femoral head
when treating unstable SCFE. However, conflicting clinical out-
comes have been reported. In 2007, Kalogrianitis et al. reported that
8 of 16 patients with unstable SCFE who developed AVN after
treatment all underwent surgery between 24 and 72 h after the
onset of symptoms [18]. They also reported the absence of necrosis
in patients who were either operated on within 24 h of symptom
onset or on day 8 after symptom onset. The period between 24 h
and day 7 after symptom onset, when patients are at increased risk
of AVN, is therefore referred to as the “unsafe window”. Results of a
2015 questionnaire survey to determine the timing of unstable
SCFE treatment in Japan showed that 7% of surgeons performed
surgery within 24 h, 7% of surgeons specifically avoided the unsafe
window, while minimal attention was paid to this risk in the
remaining 86% [17]. However, multicenter studies on the treatment
of unstable SCFE have recently been conducted in Japan. These
studies showed that AVN occurred after closed reduction and fix-
ation in 2 of 11 patients (18%) when surgery was performed within
24 h of acute onset, in 3 of 15 patients (20%) who underwent sur-
gery from day 8 or later, and in 10 out of 13 patients (77%), signif-
icantly higher when compared with the other two groups, that
underwent surgery during the unsafe window period from day 2 to
day 7 [19]. In the future, this could be important information to
consider, even in Japan, when treating unstable SCFE with closed
reduction and fixation.
1.5.2. Evaluation of physeal hemodynamics
As mentioned above, there have been no evaluations of physeal
circulation, so it has not been possible to conduct a logical discus-
sion of treatment methods. However, an increasing number of
studies in recent years have described the evaluation of physeal
hemodynamics during treatment.
226 T. Otani et al. / Journal of Orthopaedic Science 23 (2018) 220e228
Firstly, contrast-enhanced MRI and bone scintigraphy can be
used for preoperative evaluation, and both methods are reported to
be suitable for certain evaluations [20,21]. Regarding in-situ fixa-
tion to treat unstable SCFE, it is reasonable to perform surgery only
after confirming that preoperative hemodynamics is favorable.
There have also been reports regarding progress towards
intraoperative evaluation of physeal circulation. Representative
methods of evaluating circulation are confirmation of bleeding af-
ter drilling the femoral head (Fig. 8) and monitoring the pressure
within the femoral head (intracranial pressure: ICP) by laser
doppler flowmetry. Confirmation of bleeding after drilling the
femoral head is easy and does not require equipment, although
generally, the procedure is only possible with open surgeries,
which will be described later. Gill et al. studied the clinical signif-
icance of this method in patients with femoral neck fractures by
confirming bleeding after drilling the femoral head, and reported
that the sensitivity and specificity, which predict postoperative
AVN, were both 100% [22]. Meanwhile, monitoring ICP requires
specialized equipment, although this method can be performed
during closed surgery that does not involve opening the joint.
Schrader et al. first performed a closed reduction and fixation using
cannulated screws, then removed the guide wire and inserted an
ICP monitor to evaluate circulation in the femoral head instead [23].
They also performed articular decompression via percutaneous
arthrotomy in 6 patients with unfavorable physeal circulation.
Their report indicates that circulation was reestablished in all pa-
tients, and none of the patients developed AVN. The most recent
studies also report that these two evaluation methods are useful for
predicting postoperative AVN [24,25].
1.5.3. Open surgeries to treat unstable SCFE
Previously, closed surgery that did not involve opening up the
joint was usually performed to treat SCFE. However, open surgeries
have been increasingly adopted as a form of treatment in recent years.
(1) Open surgery via an anterior approach to treat unstable SCFE
Unstable SCFE may be complicated by AVN of the femoral head
when there is direct injury, such as rupture, kinking, and stretching
of the nutrient vessels supplying the femoral head. AVN may also
occur from increased intraarticular pressure due to a hematoma,
which is important to keep in mind. For this reason, articular
decompression is recommended after gentle manual reduction
and fixation during closed surgery. Although joint aspiration is
Fig. 8. Intraoperative assessment of physeal hemodynamics. a. A 2-mm drill hole is made on the epiphysis with a KW. b. Epiphyseal blood flow is confirmed by bleeding from the
drill hole.
performed as a method of articular decompression, capsulotomy is
reported to be a more effective method. Capsulotomy entails
making a small percutaneous incision, or performing a mini-open
procedure, and according to a report, it is a useful method of sup-
porting manual palpation and reduction of slippage [26]. However,
this report does not mention evaluation of femoral head blood flow
through an arthrotomy.
Unstable SCFE can be treated by performing capsulotomy, which
enables direct intraarticular examination, and the authors would
like to highlight the following key points related to this procedure.
i) It is not easy to diagnose actual physeal stability (with or
without separation of the epiphysis from the metaphysis), as
mentioned under the section on disease staging. However,
accurate diagnosis is possible if the joint is opened.
ii) The procedure allows direct confirmation of the status of
reduction.
iii) Confirmation of bleeding after drilling the epiphysis following
reduction and fixation is highly likely to prevent AVN.
iv) The procedure enables resection of protruded anterior met-
aphysis that cause FAI.
v) The procedure helps to perform joint decompression
through wound closure without suturing the joint capsule.
Surgery is performed via an anterolateral approach with the
patient in the lateral decubitus position. We believe that it would
be reasonable and beneficial to extend the surgery intraoperatively
to the Dunn or modified Dunn procedure in only those cases in
which bleeding from epiphyseal drilling cannot be confirmed, in
order to directly examine and treat the nutrient vessels on the
posterior surface of the femoral neck. Although clinical trials have
just started to determine whether this method of treating unstable
SCFE delivers clinical benefit, favorable results have been reported
in a small number of patients (Figs. 9 and 10) [27].
The authors believe that this treatment concept, to directly
assess the femoral head hemodynamics intraoperatively through
arthrotomy in order to prevent postoperative osteonecrosis, could
be applied in the treatment of femoral neck fractures in younger
population especially in child.
(2) Dunn and modified Dunn procedures
The nutrient vessels supplying the epiphysis run along the
posterior surface of the femoral neck; thus, it is not possible to
 T. Otani et al. / Journal of Orthopaedic Science 23 (2018) 220e228 227

Fig. 9. Case 2: 13-year-old boy with left unstable-type SCFE. a. Frontal view of the hips. b. Lateral view of the affected left hip. Preoperative PTA was 48 .

Fig. 10. Postoperative radiographs of Case 2. a. Frontal view. b. Lateral view. Open surgery via an anterolateral approach was performed to treat this unstable SCFE. Physeal
instability was confirmed directly and the slip was manually reduced and fixed by static fixation with two cancellous screws. After the physeal blood circulation was confirmed by
the drill method, the protruding anterior metaphysis was resected with a high-speed burr. The anterior joint capsule was not sutured to allow for joint decompression during
closure. Postoperative PTA was reduced to 21. There was no AVN on MRI taken 2 months after surgery. SCFE, slipped capital femoral epiphysis; FAI, Femoroacetabular impingement;
KW, Kirschner wire.

confirm their presence or protect these vessels when the joint is
opened via an anterior approach. Dunn osteotomized the greater
trochanter to obtain a wide exposure, examined the entire hip
joint, protecting the retinacular vessels running along the pos-
terior surface of the femoral neck under direct visualization
while performing either reduction and fixation of slippage or
osteotomy at this site [15]. Ganz reported a modified Dunn pro-
cedure, which involved performing the original Dunn procedure
after surgical dislocation of the epiphysis, since it is technically
challenging to operate on the femoral neck to the epiphysis while
it is within the acetabulum. The modified Dunn procedure is
reported to have favorable postoperative outcomes, although
caution is required because of the high rate of complications due
to the technical difficulty of the procedure [28]. Additionally, a
recent report indicated that outcomes were less favorable in
patients with stable SCFE who were treated using the modified
Dunn procedure compared with unstable SCFE patients [29].
Stable SCFE patients suffered a higher rate of complications with
AVN, and a new destructive failure mode, known as iatrogenic
anterolateral instability of the hip, was reported [30]. Thus,
caution is required.
1.6. Practical application of arthroscopy during SCFE treatment
Among the modes of surgical treatment for hip joint disorders in
recent years, the increased use of arthroscopy for diagnosis and
treatment has been remarkable. There have even been reports
regarding SCFE treatment including arthroscopic bumpectomy and
joint decompression performed during the first stage treatment,
and arthroscopic bumpectomy performed during the second stage
treatment. In the future, we will need to focus on whether this
technique delivers clinical benefits in terms of accurate diagnosis of
physeal stability, evaluation of physeal hemodynamics, reduction
and fixation of the epiphysis, and FAI treatment.
2. Conclusion
SCFE has been known as a major hip disorder for a very long
time, although diagnosis and treatment are still considered to be in
development. One possible reason could be that most cases of SCFE
were previously treated with closed procedures. The majority of
surgeons who have a wealth of experience with treating SCFE have
also never seen macroscopic findings of the slip itself. Going
228 T. Otani et al. / Journal of Orthopaedic Science 23 (2018) 220e228

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