The Journal of Bone and Joint Surgery (American) 84:1305-1314 (2002)
© 2002 The Journal of Bone and Joint Surgery, Inc.
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
W. Randall Schultz, MD, MS,
James N. Weinstein, DO, MS,
Stuart L. Weinstein, MD and
Brian G. Smith, MD
Investigation performed at the Department of Orthopaedics, Dartmouth-Hitchcock
Medical Center, Lebanon, New Hampshire; Department of Orthopedic
Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa;
Department of Orthopedic Surgery, Connecticut Children's Medical
Center, Hartford, Connecticut; and the Center for Evaluative Clinical Sciences
at Dartmouth College, Hanover, New Hampshire
W. Randall Schultz, MD, MS
James N. Weinstein, DO, MS
Department of Orthopaedics, Dartmouth-Hitchcock Medical Center,
One Medical Center Drive, Lebanon, NH 03756
Stuart L. Weinstein, MD
Department of Orthopedic Surgery, University of Iowa Hospitals
and Clinics, 200 Hawkins Drive, Iowa City, IA 52242
Brian G. Smith, MD
Department of Orthopedic Surgery, Connecticut Children's Medical
Center, 282 Washington Street, Hartford, CT 06106
The authors did not receive grants or outside funding in support
of their research or preparation of this manuscript. They 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 authors are
affiliated or associated.
A commentary is available with the electronic versions of this article,
on our web site (www.jbjs.org) and on our quarterly CD-ROM (call
our subscription department, at 781-449-9780, to order the CD-ROM).
Background:
The risk of a contralateral slip in patients who are first seen with
a unilateral slipped capital femoral epiphysis has been reported
to be 2335 times higher than the risk of an initial slip. The overall
prevalence of bilaterality varies widely throughout the literature,
with some reports indicating rates as high as 80%. This finding
has led many authors to recommend prophylactic pinning of the contralateral
asymptomatic hip in patients presenting with a unilateral slipped
capital femoral epiphysis.
Methods:
A decision analysis model with probabilities for the occurrence
of contralateral slip and for the severity of slip at different
intervals of follow-up was used in the present study. These probabilities
were compared with those for various outcomes when the contralateral
hip is prophylactically pinned. Scores representing long-term outcome,
according to the Iowa hip-rating system, were used in the model
as a measure of utility. The probabilities of contralateral slip
and the rates of slip severity were taken from large retrospective
series. All meaningful clinical scenarios with regard to long-term
outcome for the hip were considered in the model. Variables of uncertainty were
subjected to sensitivity analyses in order to explore the effect
on outcome over the range of plausible values for variables of interest.
Results:
The results showed a benefit in the long-term outcome for patients
who had prophylactic pinning of the contralateral hip. The threshold
level at which a benefit is obtained with prophylactic pinning is
expressed according to the rates of sequential slip, rates of slips
overlooked at follow-up, and complications associated with prophylactic
pinning of the contralateral hip.
Conclusions:
The decision model shows that, when pooled data are used to predict
probabilities of sequential slip, treatment of the contralateral
hip with prophylactic pinning is beneficial to the long-term outcome
for that hip. When considering prophylactic pinning of the contralateral
hip, the clinician should use sound clinical judgment with respect
to the age, sex, and endocrine status of the patient. Long-term
follow-up studies are needed to establish the efficacy of prophylactic
pinning, but the predictions in the present study, which are based
on findings in the literature, support the safety of this procedure.
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