Maranho Daniel A, Miller Patricia E, Novais Eduardo N
Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA.
Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, SP, Brazil.
J Pediatr Orthop. 2018 Aug;38(7):e371-e376. doi: 10.1097/BPO.0000000000001198.
A rotational mechanism of slipped capital femoral epiphysis (SCFE) in which the epiphyseal tubercle acts as a fulcrum has been recently described. However, there is limited radiographic evidence supporting this theory. We aimed to investigate whether a radiographic lucency around the epiphyseal tubercle (peritubercle lucency sign) could be observed before or at the diagnosis of a subsequent slip in patients initially presenting with unilateral SCFE.
We evaluated 70 patients with unilateral SCFE who were followed until a contralateral slip was diagnosed, and 180 patients with unilateral SCFE who had no contralateral slip until skeletal maturity between 2000 and 2017. We revised anteroposterior and lateral radiographs from the initial presentation, surveillance, and diagnosis of a contralateral SCFE. The presence or absence of the peritubercle lucency sign in the contralateral initially uninvolved hip was recorded for every radiograph. The presence of hip pain, and the presence of classic radiographic parameters for SCFE diagnosis (epiphyseal tilt and Klein's line) were recorded when the peritubercle lucency sign became noticeable.
The peritubercle lucency sign was observed in 84% [59/70; 95% confidence interval (CI), 73%-92%] of the patients who developed contralateral slip. Most patients (46/59=78%; 95% CI, 65%-87%; P<0.001) had the peritubercle lucency sign visible within 9 months after the initial diagnosis of unilateral SCFE. The sign preceded the definitive diagnosis of the contralateral slip at a median of 9 weeks (interquartile range, 0 to 10 wk). At the time of first observation of the peritubercle lucency sign, 36% (25/70; 95% CI, 25%-48%) of the patients were asymptomatic and 49% (34/70; 95% CI, 36%-61%) of the hips showed no abnormalities in the tilt angle or the Klein line. Among patients who did not experience a contralateral slip (n=180), the sign was observed in 2 patients (1.1%; 95% CI, 0.2%-4.4%). The sensitivity was 84% and specificity was 99%.
A peritubercle lucency is an early imaging sign, present in >80% of contralateral slips following an initial presentation of unilateral SCFE. The presence of the peritubercle lucency sign may be helpful for contralateral hip surveillance. Future studies are necessary to establish the clinical validity of the peritubercle lucency sign and whether it may serve as a predictor of contralateral involvement.
Diagnostic level III.
最近有人提出一种股骨头骨骺滑脱（SCFE）的旋转机制，其中骨骺结节作为支点。然而，支持这一理论的影像学证据有限。我们旨在调查在最初表现为单侧SCFE的患者中，在对侧发生滑脱之前或诊断时，是否能观察到骨骺结节周围的透亮影（结节周围透亮征）。
我们评估了70例单侧SCFE患者，这些患者一直随访至对侧发生滑脱被诊断出来，以及180例单侧SCFE患者，这些患者在2000年至2017年期间直至骨骼成熟均未发生对侧滑脱。我们复查了从最初就诊、随访以及对侧SCFE诊断时的前后位和侧位X线片。记录每次X线片上对侧最初未受累髋关节的结节周围透亮征是否存在。当结节周围透亮征变得明显时，记录髋关节疼痛的存在情况以及SCFE诊断的经典影像学参数（骨骺倾斜度和克莱因线）的存在情况。
在发生对侧滑脱的患者中，84%[59/70；95%置信区间（CI），73%-92%]观察到结节周围透亮征。大多数患者（46/59 = 78%；95% CI，65%-87%；P<0.001）在单侧SCFE初次诊断后9个月内可见结节周围透亮征。该征象在对侧滑脱确诊前出现，中位时间为9周（四分位间距，0至10周）。在首次观察到结节周围透亮征时，36%（25/70；95% CI，25%-48%）的患者无症状，49%（34/70；95% CI，36%-61%）的髋关节在倾斜角度或克莱因线上无异常。在未发生对侧滑脱的患者（n = 180）中，2例患者（1.1%；95% CI，0.2%-4.4%）观察到该征象。敏感性为84%，特异性为99%。
结节周围透亮是一种早期影像学征象，在单侧SCFE初次表现后，超过80%的对侧滑脱中存在。结节周围透亮征的存在可能有助于对侧髋关节的监测。未来有必要进行研究以确定结节周围透亮征的临床有效性以及它是否可作为对侧受累的预测指标。
诊断性III级。
