My Technique for Stable SCFE Pinning

M A R T I N J . H E R M A N M D

P R O F E S S O R O F O R T H O P E D I C S U R G E R Y A N D P E D I A T R I C S

D R E X E L U N I V E R S I T Y C O L L E G E O F M E D I C I N E

S T . C H R I S T O P H E R ’ S H O S P I T A L F O R C H I L D R E NP H I L A D E L P H I A , P A

12 yo girl complaining of R knee painWalking with a limp x 6 weeks

Examination

R out-toed gait

R hip ROM Flexion 0-110°

Abduction 50°

IR 10°, ER 60°

Radiographs

Diagnosis: Stable Grade 1 SCFE

Type : Idiopathic Age 12

No risk factors

Thyroid disease

Renal disease

Loder Classification: Stable Walking

“Chronic SCFE”

Grade 1 <25% slip

Treatment : IN SITU SCREW FIXATION

Admit

Next-day surgery

Bedrest

Preop discussion:

Surgery to prevent progression/acute slip

Percutaneous technique

Complications Infection

Implant issues

Future surgery

Opposite hip

FAI

OR Set-Up

Radiolucent table Fracture table

C-arm from side opposite of the SCFE or 2 C-arms

Lovell and Winter’s 7th edition, Pediatric Orthopedics, 2014

Step 1Mark the Incision Site

A

B

C D

Anterior Hip Incision

Step 2Place the Guide Wire

6.5-7.3mm cannulated screw set

Limited passes

Stress riser

Avoid bending the wire

Can CROSS-CUT the wire

Guidewire Central in Epiphysis

Entry Point of the Screw

ANTERIOR neck

Grade 1 or more

Aim posteriorly

Pre- or minimal slips

Lateral metaphysis

Above lesser trochanter

RISK of fracture if too distal

Step 3Overdrill the Guidewire

Clean drill flutes at 4-6 cm

Drill up to the physis

CHECK that the wire does not advance

Step 4Place the Screw over the Guidewire

Measure length

Fully threaded (or long-threaded) Compression (lag effect) NOT necessary

IDEAL Placement• NOT in joint• Central in epiphysis• 4-5 threads across physis

Step 5Critically Assess Screw Placement

LIVE fluoroscopy NOT in the joint

NOT proximal to intertrochanteric line

Impingement

NOT too long

Loosening

Goodwin et al, JPO, 2006

BAD – IMPINGES IN FLEXION

GOOD

Post-Op Care

Crutches x 4 weeks

TTWB

Active ROM at home Follow-up

1 w for ROM/wound check

4 w for XR

Begin PT

Q4 months for exam and XR

Assess physeal closure

Check for contralateral SCFE (30%)