Finding the Best Treatment for Stable but Severe Slipped Capital Femoral Epiphysis

Kevin E. Klingele, MD

Kevin E. Klingele, MD, chief of Orthopaedic Surgery at Nationwide Children’s Hospital

A novel comparison of the modified Dunn procedure for children with stable versus unstable slipped capital femoral epiphysis (SCFE) has identified a new target to improve surgical outcomes.

US News Badge OrthopedicsUS News Badge Honor RollThe modified Dunn procedure was controversial for many years due to the high rate of avascular necrosis after surgery, which many studies found to be as high as 60%. Surgeons at Nationwide Children’s Hospital managed to achieve far lower than average postsurgical avascular necrosis rates for unstable SCFE cases, however (~6%, which they published in 2018 in the Journal of Pediatric Orthopedics). In an attempt to offer better future mobility outcomes for other patients as well, they then extended the use of the modified Dunn procedure to severe cases of stable, chronic SCFE.

In the first known comparison of outcomes for patients with stable versus unstable slipped SCFE undergoing the modified Dunn procedure, surgeons at Nationwide Children’s found that the procedure can effectively treat both acute and chronic SCFE. However, those with stable SCFE had a higher postsurgical complication rate, primarily due to the co-occurrence of avascular necrosis and postoperative instability. In patients without postoperative instability of the hip, however, avascular necrosis risk was similar across the groups.

“The modified Dunn procedure is very effective and relatively safe in acute unstable slips, but it needs to be used more cautiously in stable chronic cases — especially those with a more severe slip,” says Kevin E. Klingele, MD, chief of Orthopaedic Surgery at Nationwide Children’s and senior author on the latest study, also published in the Journal of Pediatric Orthopedics. “Avoiding postoperative instability may be the key to lowering complication or avascular necrosis rates in this procedure to a more acceptable level for severe, stable slip patients.”

 

Since conducting the research, Dr. Klingele and the team’s other orthopedic surgeons have attempted to eliminate postoperative instability using relative femoral neck lengthening, longer postoperative leg bracing and motion restrictions, and capsulorrhaphy (suturing to tighten the hip joint). They have had no postoperative slips in patients with chronic, stable SCFE since.

“For patients with severe stable slips, outcomes from in situ screw fixation alone are not good, but we now also know that the modified Dunn procedure for these cases is different than using it for acute, unstable SCFE — you have to be more careful to avoid postoperative complications,” Dr. Klingele says. “If we can eliminate that additional risk, though, we will be on our way to reaching the ideal treatment outcome: minimal complications with the best long-term hip function.”

REFERENCES:
Davis RL 2nd, Samora WP 3rd, Persinger F, Klingele KE. Treatment of unstable versus stable slipped capital femoral epiphysis using the modified Dunn procedure. Journal of Pediatric Orthopedics. 2019;39(8):411-415. Persinger F, Davis RL 2nd, Samora WP, Klingele KE. Treatment of unstable slipped capital epiphysis via the modified Dunn procedure. Journal of Pediatric Orthopedics. 2018;38(1):3-8.

A Decade of Remarkable Transformation: Orthopaedics

From limb lengthening to hip preservation, from comprehensive spine care to sports medicine and adaptive sports medicine, and from advanced care for musculoskeletal oncology patients to basic science research that moves the field forward, the Department of Orthopaedics has established a designated initiative to solve the most complex programs of the field over the last decade.

  • 2013: Kevin Klingele, MD, Named Chief of Orthopaedics
  • 2016: Nationwide Children's Develops Orthopaedic Quality Improvement and Research Divisions
  • 2016: Dr. Christopher Iobst Joins to Head the New Center for Limb Lengthening and Reconstruction
  • 2017: Gift from Honda Helps Build Center for Gait Analysis and Mobility Enhancement
  • 2019: Nationwide Children's Launches Both the Center for Hip Preservation and the Center for Comprehensive Spine Care
  • 2020: Ranked #8 by U.S. News & World Report — Fourth Consecutive Year in Top 10