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Traumatic exacerbation of patient's symptoms
9%
103/1096
Placement of the pin tip in the anterior-superior quadrant of the femoral head
59%
643/1096
Not performing a closed reduction of the slipped epiphysis
4%
40/1096
Use of a single pin rather than two pins
3%
34/1096
Presentation with grade II slip
24%
267/1096
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The patient is presenting with chondrolysis of the left hip after in situ pinning of an unstable slipped capital femoral epiphysis (SCFE). This is associated with the placement of the tip of the pin in the anterosuperior quadrant of the femoral head. SCFE is the pathologic displacement of the proximal femoral epiphysis relative to the proximal femoral metaphysis. The condition is most common in obese adolescent males but can occur in patients with endocrinopathies. Treatment involves in situ pin fixation with or without capsular decompression. During pin fixation, there is a risk of joint penetration with the tip of the pin if it is placed in the anterosuperior quadrant of the femoral head. This can lead to progressive chondrolysis of the femoroacetabular joint, which manifests with activity-related pain and joint space narrowing on radiographs. Loder performed a systematic review of avascular necrosis (AVN) of the hip following unstable SCFE. The author reported an AVN rate of 21% with proposed mechanisms consisting of retinacular vessel kinking, elevated intracapsular pressure, and possible tearing of the femoral head blood supply. The author stated AVN will never be a "never" event in the treatment of unstable SCFE, but a better understanding of the etiology can potentially reduce the incidence. Stambough, et al. performed a retrospective study of 80 patients presenting with SCFE treated with in situ percutaneous pinning. They reported a higher complication rate with an increasing number of pins placed in the femoral neck with fewer complications associated with a more inferior pin position in the femoral head. They concluded placing the pin tip away from the superior and anterior quadrants there was decreased complication rate. Incorrect answers Answer 1: Traumatic worsening of SCFE to an unstable slip is not associated with the development of chondrolysis after pin fixation. Answer 3: Closed reduction maneuvers for SCFE are not recommended as it is associated with the development of AVN. Answer 4: The use of two pins is associated with improved stability for unstable slips, but some authors report increased complication rates with two-pin fixation. Two-pin fixation is not specifically associated with chondrolysis. Answer 5: The grade of the slip at the initial presentation is not associated with the development of chondrolysis.
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