Daniel A Maranho1,2, Patricia E Miller1, Eduardo N Novais1. 1. Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA. 2. Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, SP, Brazil.
Abstract
BACKGROUND: A rotational mechanism of slipped capital femoral epiphysis (SCFE) in which the epiphyseal tubercle acts as a fulcrum has been recently described. However, there is limited radiographic evidence supporting this theory. We aimed to investigate whether a radiographic lucency around the epiphyseal tubercle (peritubercle lucency sign) could be observed before or at the diagnosis of a subsequent slip in patients initially presenting with unilateral SCFE. METHODS: We evaluated 70 patients with unilateral SCFE who were followed until a contralateral slip was diagnosed, and 180 patients with unilateral SCFE who had no contralateral slip until skeletal maturity between 2000 and 2017. We revised anteroposterior and lateral radiographs from the initial presentation, surveillance, and diagnosis of a contralateral SCFE. The presence or absence of the peritubercle lucency sign in the contralateral initially uninvolved hip was recorded for every radiograph. The presence of hip pain, and the presence of classic radiographic parameters for SCFE diagnosis (epiphyseal tilt and Klein's line) were recorded when the peritubercle lucency sign became noticeable. RESULTS: The peritubercle lucency sign was observed in 84% [59/70; 95% confidence interval (CI), 73%-92%] of the patients who developed contralateral slip. Most patients (46/59=78%; 95% CI, 65%-87%; P<0.001) had the peritubercle lucency sign visible within 9 months after the initial diagnosis of unilateral SCFE. The sign preceded the definitive diagnosis of the contralateral slip at a median of 9 weeks (interquartile range, 0 to 10 wk). At the time of first observation of the peritubercle lucency sign, 36% (25/70; 95% CI, 25%-48%) of the patients were asymptomatic and 49% (34/70; 95% CI, 36%-61%) of the hips showed no abnormalities in the tilt angle or the Klein line. Among patients who did not experience a contralateral slip (n=180), the sign was observed in 2 patients (1.1%; 95% CI, 0.2%-4.4%). The sensitivity was 84% and specificity was 99%. CONCLUSIONS: A peritubercle lucency is an early imaging sign, present in >80% of contralateral slips following an initial presentation of unilateral SCFE. The presence of the peritubercle lucency sign may be helpful for contralateral hip surveillance. Future studies are necessary to establish the clinical validity of the peritubercle lucency sign and whether it may serve as a predictor of contralateral involvement. LEVEL OF EVIDENCE: Diagnostic level III.
BACKGROUND: A rotational mechanism of slipped capital femoral epiphysis (SCFE) in which the epiphyseal tubercle acts as a fulcrum has been recently described. However, there is limited radiographic evidence supporting this theory. We aimed to investigate whether a radiographic lucency around the epiphyseal tubercle (peritubercle lucency sign) could be observed before or at the diagnosis of a subsequent slip in patients initially presenting with unilateral SCFE. METHODS: We evaluated 70 patients with unilateral SCFE who were followed until a contralateral slip was diagnosed, and 180 patients with unilateral SCFE who had no contralateral slip until skeletal maturity between 2000 and 2017. We revised anteroposterior and lateral radiographs from the initial presentation, surveillance, and diagnosis of a contralateral SCFE. The presence or absence of the peritubercle lucency sign in the contralateral initially uninvolved hip was recorded for every radiograph. The presence of hip pain, and the presence of classic radiographic parameters for SCFE diagnosis (epiphyseal tilt and Klein's line) were recorded when the peritubercle lucency sign became noticeable. RESULTS: The peritubercle lucency sign was observed in 84% [59/70; 95% confidence interval (CI), 73%-92%] of the patients who developed contralateral slip. Most patients (46/59=78%; 95% CI, 65%-87%; P<0.001) had the peritubercle lucency sign visible within 9 months after the initial diagnosis of unilateral SCFE. The sign preceded the definitive diagnosis of the contralateral slip at a median of 9 weeks (interquartile range, 0 to 10 wk). At the time of first observation of the peritubercle lucency sign, 36% (25/70; 95% CI, 25%-48%) of the patients were asymptomatic and 49% (34/70; 95% CI, 36%-61%) of the hips showed no abnormalities in the tilt angle or the Klein line. Among patients who did not experience a contralateral slip (n=180), the sign was observed in 2 patients (1.1%; 95% CI, 0.2%-4.4%). The sensitivity was 84% and specificity was 99%. CONCLUSIONS: A peritubercle lucency is an early imaging sign, present in >80% of contralateral slips following an initial presentation of unilateral SCFE. The presence of the peritubercle lucency sign may be helpful for contralateral hip surveillance. Future studies are necessary to establish the clinical validity of the peritubercle lucency sign and whether it may serve as a predictor of contralateral involvement. LEVEL OF EVIDENCE: Diagnostic level III.
Authors: Shayan Hosseinzadeh; Eduardo N Novais; Alireza Emami; Gabriela Portilla; Daniel A Maranho; Young-Jo Kim; Ata M Kiapour Journal: Clin Orthop Relat Res Date: 2021-05-01 Impact factor: 4.176
Authors: Eduardo N Novais; Shayan Hosseinzadeh; Seyed Alireza Emami; Daniel A Maranho; Young-Jo Kim; Ata M Kiapour Journal: Clin Orthop Relat Res Date: 2021-05-01 Impact factor: 4.176
Authors: Daniel A Maranho; Sarah D Bixby; Patricia E Miller; Shayan Hosseinzadeh; Michael George; Young-Jo Kim; Eduardo N Novais Journal: Clin Orthop Relat Res Date: 2020-05 Impact factor: 4.755