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.
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.
Schultz
W Randall
WR
Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire 03756, USA.
Weinstein
James N
JN
Weinstein
Stuart L
SL
Smith
Brian G
BG
D001858:Bone Nails; D003661:Decision Support Techniques; D004839:Epiphyses, Slipped / Q000000981:diagnostic imaging / Q000453:epidemiology / Q000601:surgery*; D006801:Humans; D019637:Orthopedic Procedures; D011859:Radiography; D016896:Treatment Outcome