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Arch Orthop Trauma Surg (1989) 108 : 336-338 Ahves~Orthopaedic

ndTrauma Surgery
9 Springer-Verlag 1989

Acute-on-Chronic Bilateral Reversed Slipped Capital Femoral

Epiphysis Managed by Imhauser-Weber Osteotomy

M. A. Scher, M. B. E. Sweet, and I. Jakim

Department of Orthopaedic Surgery and MRC Bone and Joint Research Unit, University of the Witwatersrand, Johannesburg,
South Africa

Summary. I n a rare case of progressive bilateral valgus- Anteroposterior radiographs of the pelvis with the hips in
slipped capital femoral epiphysis, modified Imhauser- identical degrees of rotation had been taken 9 months before
referral: there was an exaggerated neck shaft angle of 168~
W e b e r o s t e o t o m i e s w e r e c a r r i e d out. T h e o s t e o t o m i e s
the right and of 170~ on the left. The growth plate was horizon-
a l l o w e d for s i g n i f i c a n t v a r u s c o r r e c t i o n a n d t h u s in- tal on the right and tilted into mild valgus on the left. The ace-
c l u d e d s h o r t e n i n g o f t h e n e c k a n d distal t r a n s f e r of tabular indices were normal. The capital epiphyses were sub-
the greater trochanter. The planning technique of the luxed laterally - more so on the left, due to valgus tilt (Fig. 1).
c o m p l e x o s t e o t o m y is d i s c u s s e d . A t 5 - y e a r f o l l o w - u p Similar radiographs taken on presentation 9 months later
(Fig. 2) revealed further valgus slip of the capital epiphyses and
the patient had a gratifying result.
loss of coverage bilaterally. The growth plates were still open
and displayed increased valgus tilt with evidence of lateral com-
pressive changes. Lateral views demonstrated posterior slip of
Reversed or valgus-slipped capital femoral epiphysis the capital epiphyses measuring 25~ on the right and 30~ on the
is v e r y r a r e . O f t h e 12 cases r e p o r t e d i n t h e l i t e r a t u r e left (Fig. 3). There was no evidence of any endocrinological ab-
[ 1 - 5 , 9, 11], to o u r k n o w l e d g e o n l y t h r e e w e r e b i l a t - normality.
e r a l [3, 5]. W e r e p o r t a c a s e o f a c u t e - o n - c h r o n i c re- The osteotomies were planned from biplanar tracings of
the radiographs, modifying the Imhauser-Weber technique to
v e r s e d b i l a t e r a l slip ( v a l g u s a n d p o s t e r i o r ) o f t h e cap- allow correction of posterolateral slip (Fig. 4). The maximum
ital f e m o r a l epiphysis i n which it was c o n s i d e r e d neces- direction of slip was valgus, the posterior component being of
sary to p e r f o r m b i l a t e r a l m o d i f i e d I m h a u s e r - W e b e r moderate degree. Thus the osteotomies were calculated to give
o s t e o t o m y [6]. 45~ of varus and 25 ~ of flexion on the left and 35~ of varus and
20~ of flexion on the right. In view of the magnitude of varus
correction, provision was made for shortening of the neck and
Case Report distal transfer of the greater trochanter.
Intertrochanteric osteotomies were carried out 4 months
A 14-year-old girl was referred with a history of spontaneous apart, starting with the right hip. The capsule was opened and
onset of increasing bilateral hip pai n of one year's duration; the epiphysis was transfixed with a cancellous AO screw. The
this had forced her to give up all physical activities. The left osteotomy was carried out as planned and achieved the desired
side was worse than the right. She had a left-sided limp and re- correction. Rotational correction was assessed intraoperatively.
duced walking ability (500 metres) and she experienced diffi- The osteotomy was stabilized with an adolescent-type 90~ A O
culty in sitting on a low chair. The patient's past medical and blade plate. The patient's initial postoperative course was une-
family history was noncontributory. Examination showed the ventful. She was mobilized with touch weight bearing on crutches
patient to be postpubertal; her height was 172cm, her weight a few days after surgery and discharged on the sixth postopera-
56 kg. General physical examination revealed no abnormalities. tive day. When healing of the osteotomy was considered ade-
Specifically, there was no abnormal ligamentous laxity. She quate the second procedure was carried out as before. The
walked with a bilateral antalgic limp combined with a left-sided early postoperative course was uneventful. However, her sub-
Trendelenburg lurch. There was no rotational deformity in the sequent compliance regarding restriction of weight bearing was
lower limbs. poor, resulting in implant failure with loss of position at the
Flexion was to 90 ~ on the left and 100~ on the right. There osteotomy site on the left. Six months postoperatively the left
was bilateral hyperextension, 40~ on the left and 25~ on the osteotomy was repeated and fixation achieved with an adult
right. Other movements were within normal limits. Pain was A O 130~ blade plate.
particularly marked at the extremes of motion on both sides. Serial radiographs over the ensuing 12 months demonstrated
Clinically, the legs were of equal length. Other than abductor the development of mild flattening of the left femoral head with
weakness on the left, muscle power was within normal limits. a small underlying, cranially positioned avascular segment and
slight narrowing of the superior joint space.
Offprint requests to: M.A. Scher, P.O.Box 91285, Auckland The patient has been followed up annually for 5 years. She
Park 2006, South Africa has remained asymptomatic and returned to sporting activities
M. A. Scher et al. : Bilateral Reversed Slipped Capital Femoral Epiphysis 337

Fig. 1. Anteroposterior view of the pelvis, showing both hips 9 epiphysis (so-called head-in-neck deformity) accom-
months before presentation. The exaggerated neck-shaft panying a horizontal or even laterally tilted growth
angle and early reversed slipped femoral capital epiphysis are
evident plate is a well-recognized iatrogenic deformity that
occurs during the treatment of congenital hip dysplasia
Fig. 2. Anteroposterior view of the pelvis at age 14 years.
Progressive lateral slip of the capital femoral epiphysis has following prolonged casting in the Lorentz position
occurred. There is valgus tilt of the growth plate and uncover- [10]. We consider this to be an entity distinct from
ing of the capital epiphysis spontaneous reversed slipped capital femoral epiphysis
Fig. 3a, b. Lateral radiographs of the right (a) and left (b) hips seen in adolescence. To our knowledge 12 cases of
illustrating posterior slip of both capital epiphyses true valgus slip have been described [1-5, 9, 11]; of
these, three were bilateral [3, 5].
The clinical and radiographic features in our pa-
including tennis and aerobic classes. Her gait is normal and she tient strongly suggested that a progressive acute-on-
has a pain-free fuctional range of motion in both hips (flexion chronic slip had occurred in the presence of an open
0~ ~ on each side without any extension). Abductor power
is normal on both sides. The lower limbs are of equal length. growth plate in both hips. Further, both the degree of
There has been no further progression of radiographic changes containment and coverage were unacceptable. These
in the left hip joint (Fig. 5). considerations led us to decide that an intertrochan-
teric osteotomy should be combined with transfixion
of the capital epiphysis.
Discussion The Imhauser-Weber osteotomy for moderate to
severe posteromedial slip in which the major compo-
Valgus slip of the femoral capital epiphysis was first nent is posterior has gained wide acceptance in Europe
described by Mtiller in 1926, associated with acetabu- [6]. In planning the operation in this case we had to
lar dysplasia [8]. A valgus tilt of the capital femoral make provision for correction of the lateral (valgus)
338 M.A. Scher et al.: Bilateral Reversed Slipped Capital Femoral Epiphysis

Fig. 4a, b. Preoperative planning

diagrams of the right hip: a An-
teroposterior plan to allow for 35~
varus, shortening of the femoral
neck and distalization of the
greater trochanter; b lateral plan
giving 20~ of flexion and transfix-
ion of the capital epiphysis with a
35-mm cancellous screw. Overall
femoral shortening was calculated
as 22 mm

the condition. This was certainly p r e s e n t in our case,

as well as in others in the literature [2, 3, 9, 11]. In all
probability there exist a n u m b e r of aetiological fac-
tors. A n increased neck shaft angle is p r e s e n t in s o m e
patients with congenital dislocation of the hip, con-
genital m u s c u l a r atonia or spastic cerebral palsy with
a d d u c t o r d o m i n a n c e [10], despite which r e v e r s e d slip
is not e n c o u n t e r e d .

1. Carlioz H, Vogt JC, Barba L, Doursounian L (1984) Treat-
ment of slipped upper femoral epiphysis: 80 cases operated
Fig. 5. Anteroposterior radiograph of pelvis and both hips 5 on over 10 years (1968-1978). J Pediatr Orthop 4 : 153-161
years postoperatively. On the left side there is slight loss of 2. Fahey JJ, O'Brien ET (1965) Acute slipped capital femoral
superior joint space. The femoral head shows some deformity epiphysis. J Bone Joint Surg [Am] 47 : 1105-1127
compatible with previous avascular necrosis 3. Finch AD, Roberts WM (1946) Epiphyseal coxa valga. J
Bone Joint Surg 28: 869-872
4. Howorth MB (1949) Slipping of the upper femoral epi-
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c o m p o n e n t to the slip by an a p p r o p r i a t e varus osteo-
5. Krishnan SG, Shelton ML (1972) Bilateral "reverse" epi-
tomy. S o m e authors have cautioned against osteoto- physeolysis of the proximal femoral capital epiphysis. J
mies in excess of 20 ~ which are thought to lead to per- Nail Med Assoc 64: 437
m a n e n t limp or unsteadiness [10]. Muller [7] has de- 6. Imhauser G (1960) l)ber das Wesen der Epiphysendisloka-
scribed varus corrections varying f r o m 10 ~ to 40 ~ T h e tion am koxalen Femurende und ihre operative Spgtbe-
handlung. Wiederherstellungschirurgie Traumatologie 5:
o s t e o t o m y was p l a n n e d to allow shortening of the
203 -242
neck and distal transfer of the greater t r o c h a n t e r to 7. Muller ME (1973) Intertrochanteric osteotomy in the treat-
e n h a n c e a b d u c t o r function, and to result in ultimate ment of the arthritic hip joint. In: Tronzo RG (ed) Surgery
equalization of leg length u p o n correction of the op- of the hip joint. Lea & Febiger, Philadelphia, pp 627-643
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Epiphysenverschiebung. Beitr Klin Chir 137 : 148-164
T h e segmental avascular necrosis which developed
9. Skinner SR, Berkheimer GA (1978) Valgus slip of the cap-
in the left f e m o r a l h e a d was possibly related to the ital femoral epiphysis. Clin Orthop 135 : 90-92
n e e d for further surgery. Nevertheless, the result at 10. Tonnis D (1987) Congenital dysplasia and dislocation of the
5-year follow-up was very good. hip. Springer, Berlin Heidelberg NewYork, pp 19, 306-
Because of the rarity of the condition it is not pos- 307,343
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sible to postulate a p a t h o g e n e t i c m e c h a n i s m for re-
femoral epiphysis. J Bone Joint Surg [Am] 47:1128-1145
versed slip. Skinner and B e r k h e i m e r [9] have suggest-
ed an increased neck shaft angle m a y predispose to Received May 30, 1988 / Accepted March 23, 1989