What the Anesthesiologist Should Know before the Operative Procedure
Slipped capital femoral epiphysis (SCFE) is the most common hip disorder affecting adolescents. The disorder is a failure through the zone of hypertrophy of the proximal femoral growth plate typically as a result of stress or trauma. It is classified as stable or unstable based on the ability to bear weight, even with crutches.
More than 90% are classified as stable. Other classifications include acute, chronic, and acute-on-chronic. The differentiation is based on length of symptoms. Acute has symptoms less than 3 weeks, chronic has symptoms for greater than 3 weeks, and acute-on-chronic has a symptoms for greater than three weeks with a recent exacerbation.
The name is actually a misnomer; in the most common form the femoral neck metaphysis displaces anteriorly and superiorly in relation to the capital femoral epiphysis, which remains in the acetabulum.
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In 2006, the overall incidence rate was 10.8 per 100,000 children, with higher rates in blacks (24.58) and Hispanics (15.8). Males have an incidence 43% higher than females. The overall average age of presentation appears to be decreasing and was 12.1 years in 2000.
Weakness in the proximal femoral growth plate can occur as a result of obesity, endocrine disorders (hypothyroidism, panhypopituitarism, hypogonadism, growth hormone supplementation, and renal osteodystrophy), and the period of rapid growth during adolescence.
Stable SCFE typically presents with increasing hip and knee pain
1. What is the urgency of the surgery?
What is the risk of delay in order to obtain additional preoperative information?
Surgical intervention is used to prevent progression of the slip. The displacement of the epiphysis may result in osteonecrosis of the femoral head, chondrolysis, and in later life, osteoarthritis. Urgency is not usually indicated in the surgical literature other than to say that delayed repair increases the incidence of these late complications.
Emergent:Relatively rare.
Urgent:Patients with unstable SCFE may be considered in the Urgent category.
Elective:The vast majority of patients presenting for SCFE undergo elective surgery.
2. Preoperative evaluation
Most patients treated for SCFE are between 10 and 16 years of age. Patients outside of this range and those within this range that are underweight should be considered atypical and evaluation for endocrine or renal disorders should be considered. Patients within this age range and without evidence of coexisting disease generally do not require extensive work-up.
The conditions that should be evaluated in atypical situations include hypothyroidism, panhypopituitarism, hypogonadism, growth hormone supplementation, and renal osteodystrophy.
3. What are the implications of co-existing disease on perioperative care?
Pediatric patients with hypothyroidism can show an exaggerated response to surgical stimulation, may be hemodynamically unstable during anesthesia, may have pronounced depression from sedative drugs, and may have delayed emergence from anesthesia.
Patients with disorders of the growth hormone system may be short in stature, have decreased or deficient bone growth with a resulting difficult airway, and may have abnormalities of the glucose metabolism.
Patients with renal osteodystrophy have severely disordered renal function and abnormalities of serum calcium, phosphate, and parathyroid hormone (PTH).
b. Cardiovascular system
N/A
c. Pulmonary
N/A
d. Renal-GI:
Patients with renal osteodystrophy have severely disordered renal function and abnormalities of serum calcium, phosphate, and parathyroid hormone (PTH).
e. Neurologic:
N/A
f. Endocrine:
Pediatric patients with hypothyroidism can show an exagerated response to surgical stimulation, may be hemodynamically unstable during anesthesia, may have pronounced depression from sedative drugs, and may have delayed emergence from anesthesia.
Patients with disorders of the growth hormone system may be short in stature, have decreased or deficient bone growth with a resulting difficult airway, and may have abnormalities of the glucose metabolism.
g. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (eg. musculoskeletal in orthopedic procedures, hematologic in a cancer patient)
Orthopedic surgeons frequently place a screw or pin in the contralateral hip in patients with unstable SCFE.
4. What are the patient's medications and how should they be managed in the perioperative period?
N/A
h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?
N/A
i. What should be recommended with regard to continuation of medications taken chronically?
N/A
j. How To modify care for patients with known allergies –
N/A
k. Latex allergy- If the patient has a sensitivity to latex (eg. rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.
N/A
l. Does the patient have any antibiotic allergies- – Common antibiotic allergies and alternative antibiotics.]
N/A
m. Does the patient have a history of allergy to anesthesia?
N/A
5. What laboratory tests should be obtained and has everything been reviewed?
Laboratory examination generally follows the expectation for co-existing disease described above. Routine examination is not indicated for patients in the typical age band and those without other evidence of co-existing disease.
Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?
The surgical approach to this condition is relatively non-invasive. Screws and or pins may be placed percutaneously and as a result, post-operative pain is relatively mild, as orthopedic procedures go. Patients are usually kept overnight for observation and crutch training and usually discharged on post-operative day one.
Regional anesthesia
Due to the early discharge and relatively atraumatic surgical repair, “single shot” caudals or epidurals (after induction of general anesthesia) work very well in this patient population.
General anesthesia
As these are usually pediatric patients, general anesthesia is almost always indicated. Regional anesthesia (after induction) for post-operative pain control is typically offered to the patient and family.
6. What is the author's preferred method of anesthesia technique and why?
As described earlier.
a. Neurologic:
N/A
b. If the patient is intubated, are there any special criteria for extubation?
N/A
c. Postoperative management
Ketorolac and other non-steroidal antiinflammatory agents are effective analgesics in this population if not contraindicated by co-existing disease (renal osteodystrophy or any bleeding diathesis).
What's the Evidence?
Lehmann, CL, Arons, RR. “The epidemiology of slipped capital femoral epiphysis: An update”. J Pediatr Orthop. vol. 26. 2006. pp. 286-290. (This paper from the orthopedic literature discusses the epidemiology of slipped capital femoral epiphysis. It also suggests that geographical, racial and seasonal variations may affect its incidence.)
Gholve, PA, Cameron, DB, Millis, MB. “Slipped capital femoral epiphysis update”. Curr Opin Pediatr. vol. 21. 2009. pp. 39-45. (This paper from the orthopedic literature discusses the diagnostic tools and treatment options of children with slipped capital femoral epiphysis.)
Loder, RT. “Controversies in slipped capital femoral epiphysis”. Orthop Clin N Am. vol. 37. 2006. pp. 211-221. (This paper discusses the treatment of unstable slipped capital femoral epiphysis, the role of osteotomy in its treatment and the role of prophylactic fixation of the contralateral hip in patients with unilateral disease.)
Herrera-Soto, JA, VanderHave, KL. “Bilateral unstable slipped capital femoral epiphysis: A look at risk factors”. Orthopedics. vol. 34. 2011. pp. e121-e126. (A retrospective study of 7 patients who developed bilateral unstable hips with slipped capital femoral epiphysis.)
Millis, MB, Novais, EN. “In situ fixation for slipped capital femoral epiphysis: perspectives for 2011”. J Bone Joint Surg Am. vol. 93. 2011. pp. 46-51. (Discussion of the use of in situ fixation for slipped capital femoral epiphysis.)
Lazar, MA, Van Gelderen, JT. “Treatment of SCFE in a healthy 5-year-old child: case report and review”. J Pediatr Orthop B. vol. 20. 2011. pp. 232-237. (Case presentation of a 5-year-old for slipped capital femoral epiphysis.)
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