Commentary & Perspective on
"Prophylactic Pinning of the Contralateral Hip in Slipped Capital Femoral Epiphysis: Evaluation of Long-Term Outcome for the Contralateral Hip with Use of Decision Analysis"
by W. Randall Schultz, MD, MS, et al.

Commentary & Perspective by
James H. Beaty, MD*,
Campbell Clinic, Memphis, TN

Schultz et al., from the perspective of a pediatric orthopaedist with a twenty-five-year interest in slipped capital femoral epiphysis, clearly make a strong case for prophylactic pinning of the contralateral hip in patients with unilateral slipped capital femoral epiphysis. Our colleagues in Europe and other areas of the world consider the etiology of slipped capital femoral epiphysis to be an occult and subtle endocrinopathy, and many of them routinely pin the contralateral, normal hip when the unilateral slip is treated. I suspect that almost every pediatric orthopaedist in North America who reads this article would agree with pinning of the contralateral hip in children with known endocrinopathies¹.

In children with idiopathic slips, however, we are more likely to recommend careful observation with follow-up evaluations every two to three months and discussions with the patient and family about the importance of reporting any symptoms in the contralateral hip. Many orthopaedic surgeons can recall an instance in which an adolescent patient, fearing another surgical procedure, remained silent about symptoms in the contralateral hip for six to twelve months after the pinning of the symptomatic hip, thus risking an acute unstable slip that could lead to osteonecrosis.

Concerns about surgical pinning, especially the risk of chondrolysis from pin penetration of the hip joint, have largely been remedied by the use of cannulated screws, better use of fluoroscopy, and newer surgical techniques, including the use of a small skin incision instead of a large anterolateral approach^2,3. As the authors pointed out, further studies are needed to definitively determine the safety of pinning the normal, contralateral hip.

The results of this decision analysis model raise the question of whether prophylactic pinning of the contralateral, normal hip in patients with unilateral slipped capital femoral epiphysis should become the standard of care. If further studies confirm the efficacy and safety of this approach, then a change in our decision-making would be warranted.

*The author did not receive grants or outside funding in support of the research or preparation of this manuscript. He did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated.

References

1. Loder RT, Aronsson DD, Dobbs MB, Weinstein SL. Slipped capital femoral epiphysis. Instr Course Lect. 2001;50:555-70.
2. Canale ST, Casallas M, Banta JV. Displaced femoral neck fractures at the bone-screw interface after in situ fixation of slipped capital femoral epiphysis. J Pediatr Orthop. 1997;17:212-5.
3. Lindaman LM, Canale ST, Beaty JH, Warner WC. A fluoroscopic technique for determining the incision site for percutaneous fixation of slipped capital femoral epiphysis. J Pediatr Orthop. 1991;11:397-401.