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大腿骨頭すべり症

著者: 森田光明1) 大阪こどもとおとなの整形外科

著者: 亀ヶ谷真琴2) 千葉こどもとおとなの整形外科

監修: 酒井昭典 産業医科大学 整形外科学教室

著者校正/監修レビュー済:2022/05/25
患者向け説明資料

概要・推奨   

  1. 成長期に跛行を呈したり股関節のみならず大腿や膝の疼痛を訴える場合、本疾患を念頭に置いて診療を行うべきである(推奨度2)
  1. 股関節の可動性、特に屈曲した際のDrehmann徴候の有無を確認する。単純X線撮影を行い、必ず両股関節2方向撮影を行う(推奨度1)
  1. 原則的に手術適応であり、できる限り早く入院してもらう(推奨度2)
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、 著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※同効薬・小児・妊娠および授乳中の注意事項等は、海外の情報も掲載しており、日本の医療事情に適応しない場合があります。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適応の査定において保険適応及び保険適応外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適応の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
森田光明 : 特に申告事項無し[2022年]
亀ヶ谷真琴 : 特に申告事項無し[2022年]
監修:酒井昭典 : 特に申告事項無し[2022年]

改訂のポイント:
  1. 定期レビューを行い、概要・推奨について加筆修正を行った。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 成長期において、大腿骨近位骨端線(成長軟骨帯)で骨端部と骨幹端部との間ですべりが生じる疾患である。
  1. 慢性的にわずかな跛行を呈する例から(安定型・慢性型)、急激に発症し歩行不能となる(不安定型・急性型)こともあり、疼痛も股関節だけでなく大腿部や膝関節痛を訴えることも多い。
  1. 病因としては、大腿骨近位骨端線の脆弱性、力学的強度の低下と、成長期の体重や運動量の増加といった力学的負荷の増加が要因となっていると考えられる。何らかのホルモン異常が原因になっていると推測されるが、実際に明らかな内分泌疾患や数値の異常を認める例は少ない。
  1. 男児に多く好発年齢は10~14歳で、肥満傾向児に多い。両側例は10%程度だが内分泌疾患を伴うものはより高率に認める。
  1. 日本における発生頻度は、発症危険年齢の人口10万人あたり男児2.2人、女児0.8人で近年増加傾向にある。
問診・診察のポイント  
問診:
  1. 発症時期を確認する。

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文献 

W O Southwick
Osteotomy through the lesser trochanter for slipped capital femoral epiphysis.
J Bone Joint Surg Am. 1967 Jul;49(5):807-35.
Abstract/Text
PMID 6029256
R T Loder, B S Richards, P S Shapiro, L R Reznick, D D Aronson
Acute slipped capital femoral epiphysis: the importance of physeal stability.
J Bone Joint Surg Am. 1993 Aug;75(8):1134-40.
Abstract/Text To test the traditional classification system of slipped capital femoral epiphysis, we evaluated the presenting symptoms and radiographs of fifty-four patients and reclassified the slipped epiphyses as unstable or stable, rather than acute, chronic, or acute-on-chronic. Slips were considered to be unstable when the patient had such severe pain that weight-bearing was not possible even with crutches. Slips were considered to be stable when the patient could bear weight, with or without crutches. We reviewed the records on fifty-five hips in which the slip would have been classified as acute because the duration of symptoms was less than three weeks; thirty of these were unstable and twenty-five were stable. All slips were treated with internal fixation. A reduction occurred in twenty-six of the unstable hips and in two of the stable hips. Fourteen (47 per cent) of the thirty unstable hips and twenty-four (96 per cent) of the twenty-five stable hips had a satisfactory result. Avascular necrosis developed in fourteen (47 per cent) of the unstable hips and in none of the stable hips. We were not able to demonstrate an association between early reduction and the development of avascular necrosis.

PMID 8354671
A KLEIN, R J JOPLIN, J A REIDY, J HANELIN
Roentgenographic features of slipped capital femoral epiphysis.
Am J Roentgenol Radium Ther. 1951 Sep;66(3):361-74.
Abstract/Text
PMID 14878022
J R Jones, D C Paterson, T M Hillier, B K Foster
Remodelling after pinning for slipped capital femoral epiphysis.
J Bone Joint Surg Br. 1990 Jul;72(4):568-73.
Abstract/Text We assessed 70 hips at an average of 7.1 years after pinning for slipped upper femoral epiphysis to determine the frequency of remodelling, what factors influence it and its effect on the clinical outcome. Remodelling was defined by a new classification of the anterior femoral head-neck profile as seen on the lateral radiograph. Remodelling occurred in 50% of hips with a head-shaft angle of 30 degrees or more; the probability of remodelling was significantly less the greater the degree of slip, but was significantly increased if the triradiate cartilage was open at the time of presentation. We found no significant effect for age, sex, weight or length of symptoms. The range of internal rotation was significantly greater in those hips that remodelled. We support the treatment of moderate slips in skeletally immature patients by pinning in situ, since the probability of satisfactory remodelling was 75% for slips of 40 degrees or less.

PMID 2380205
Abstract/Text Various conventional roentgenographic methods have been proposed to determine the severity of chronic slipped capital femoral epiphysis (SCFE) on the sagittal plane, with some maintaining that computed tomography (CT) is more accurate and reproduces better than roentgenography. We used a modified Dunlap's technique and angular measurement to determine slip severity. Three orthopaedists obtained data from roentgenograms and CT of 20 hips with chronic SCFE. Statistical analysis showed concordance between our method and the measurements and reproducibility produced with CT. The results suggest that our method is as effective as and less expensive than CT.

PMID 1988480
Makoto Kamegaya, Takashi Saisu, Junichi Nakamura, Reiko Murakami, Yuko Segawa, Masanori Wakou
Drehmann sign and femoro-acetabular impingement in SCFE.
J Pediatr Orthop. 2011 Dec;31(8):853-7. doi: 10.1097/BPO.0b013e31822ed320.
Abstract/Text BACKGROUND: Drehmann sign is a characteristic clinical feature in slipped capital femoral epiphysis (SCFE). The presence of SCFE indicates an anatomic change of the proximal femur, which induces obligatory hip external rotation with hip flexion. In contrast, a cam-type femoro-acetabular impingement (FAI) is well known as sequelae of SCFE. The purpose of this study was to clarify the relationship between Drehmann sign and radiologic FAI.
METHODS: We studied 92 hips of 80 SCFE patients who had been treated with in situ fixation. The occurrence rate of Drehmann sign was analyzed according to the degree of remodeling (the Jones classification) and the radiologic α-angle measured in each class at the final follow-up. At a mean 12.2 years after the final follow-up, the patients' present condition was clinically investigated with a questionnaire using a part of the Harris Hip Rating Scale (HHRS). In addition, 3-dimensional computed tomography analysis was performed to clarify the anatomic relationship between the femoral head and the acetabulum during testing for Drehmann sign.
RESULTS: Among the 92 hips in the study, 60 were well remodeled (Jones type A), 24 were type B, and 8 were type C, with 6.5 years of mean follow-up. The mean of the modified α-angles for the 3 groups (A, B, and C) were 61.8, 84.7, and 119.4, respectively (P < 0.05); 25%, 75%, and 100% of the hips in the 3 groups, respectively, exhibited Drehmann sign. The set of hips (n = 41) with a positive Drehmann sign had a mean α-angle of 85.6 versus 63.0 degrees for the set of hips (n = 51) with a negative Drehmann sign (P < 0.05). Seven (13.5%) of 52 patients responding to the questionnaire reported hip pain and/or limp in the positive Drehmann sign group, but no patient in the negative sign group complained of either. Three-dimensional computed tomography delineated FAI at 2 different positions during testing for Drehmann sign.
CONCLUSIONS: Drehmann sign is highly valuable for clinically evaluating the existence of FAI and for following up with observation or realignment to prevent early osteoarthritis.

PMID 22101663
Michael K Dodds, Damian McCormack, Kevin J Mulhall
Femoroacetabular impingement after slipped capital femoral epiphysis: does slip severity predict clinical symptoms?
J Pediatr Orthop. 2009 Sep;29(6):535-9. doi: 10.1097/BPO.0b013e3181b2b3a3.
Abstract/Text BACKGROUND: Femoroacetabular impingement (FAI) may be common after slipped capital femoral epiphysis though the actual frequency is unknown. The purpose of this study was to determine the frequency of symptomatic FAI in young adults after slipped capital femoral epiphysis and define its relationship with slip severity.
METHODS: We retrospectively reviewed a consecutive series of 49 patients (65 hips) to determine patient and slip characteristics and treatments. Patients were then recalled for clinical and radiographic review to assess symptoms, particularly impingement, and outcomes after skeletal maturity.
RESULTS: Thirty-six patients (49 hips) were reviewed clinically and radiographically with a mean follow-up of 6.1 years (range: 2.2 to 13.1 y). All patients had reached skeletal maturity. Thirty-one percent (15/49) of patients complained of hip pain or stiffness, whereas 32% (16/49) had clinical signs of impingement. The Southwick slip angle and grade of slip or Loder's classification of physeal stability were not predictive of impingement at follow-up. The anterior head-neck offset angle (alpha angle) correlated most strongly with FAI (r=0.26). No pre-slips or prophylactically pinned hips developed clinical impingement in this review.
CONCLUSIONS: In the absence of radiographic indicators to predict FAI, we advocate all but those hips pinned prophylactically or for pre-slip should be followed into adulthood and clinically monitored for impingement. Grade of slip in adolescence cannot be used as a predictive tool for FAI later in life.
LEVEL OF EVIDENCE: Level II, retrospective study.

PMID 19700979
W T Ward, J Stefko, K B Wood, C L Stanitski
Fixation with a single screw for slipped capital femoral epiphysis.
J Bone Joint Surg Am. 1992 Jul;74(6):799-809.
Abstract/Text The effectiveness of a single 6.5 or seven-millimeter-diameter screw for the promotion of premature physeal closure and the provision of stability of a slipped capital femoral epiphysis was investigated. Physeal fusion was demonstrated in forty-nine (92 per cent) of fifty-three hips after fixation with a single screw. Premature fusion of the involved physis, compared with the uninvolved, contralateral physis, was documented (p less than 0.001). Epiphyseal stability, as measured by the lateral head-shaft angle, was maintained in all except one hip. An analysis of twenty-nine hips for which there was a complete set of radiographs, that were in patients who had no endocrine problems, and that were the first hips entered into the study when the patient had bilateral involvement, revealed an average time to closure of the physeal line of thirteen months. A longer time to physeal fusion was correlated with increasingly eccentric placement of the screw (r = 0.44, p = 0.016) and increasing severity of the slip (r = -0.536, p = 0.003). There was no correlation between the age at the time of the operation, race, or sex and the time to physeal fusion. Only one patient had penetration by a screw, and no chondrolysis, avascular necrosis, or other serious problems developed. Fixation with a single 6.5 or seven-millimeter-diameter screw provided adequate epiphyseal stability and promoted premature physeal fusion in our patients, while decreasing the rate of complications compared with that reported to be associated with fixation with multiple screws or pins.

PMID 1634570
Abstract/Text The author has reviewed the clinical and radiological results of 55 patients 11 to 22 years following an Imhäuser three dimensional intertrochanteric osteotomy for slipped capital femoral epiphysis. 13 additional patients responded by questionnaire. Of these 68 hips 66 were painfree and functional. One patient complained of pain (due to coxarthrosis proven by x-ray). A second patient was dissatisfied with the functional range of his hip. 40 of the 55 hips which were examined clinically and radiologically had full range of motion, 10 hips showed minimal and 5 hips significant limitation of motion. Radiologically 73% of the 55 hips examined were rated excellent or good, 27% showed beginning degenerative changes (including one patient with marked coxarthrosis). The results were greatly influenced by the severity and direction of slipping, preoperative treatment and the accuracy of operative correction. This study permits the conclusion that three dimensional intertrochanteric osteotomy prevented or at least delayed the development of degenerative changes in the majority of cases. It is possible that many of these patients will not develop coxarthrosis.

PMID 930245
Makoto Kamegaya, Takashi Saisu, Nobuyasu Ochiai, Hideshige Moriya
Preoperative assessment for intertrochanteric femoral osteotomies in severe chronic slipped capital femoral epiphysis using computed tomography.
J Pediatr Orthop B. 2005 Mar;14(2):71-8.
Abstract/Text We propose here to focus on preoperative assessment for intertrochanteric femoral osteotomies in severe slipped capital femoral epiphysis (SCFE) using computed tomography. This intertrochanteric osteotomy was preoperatively customized for each chronic SCFE patient treated, and has been performed on 22 patients with an average posterior slip angle of 55 degrees. The osteotomy is planned with images from computed tomography as follows. The angle between a provisional axis on one image and the axis of the lateral aspect of the femur on the other image is defined as alpha. When the alpha angle varies from 20 to 30 degrees, a simple flexion osteotomy is selected for correction along the axis of the lateral femur; when the alpha angle is more than 30 degrees, a flexion osteotomy along with some valgus correction should be considered; when the alpha angle is less than 20 degrees, varus correction should be added. The postoperative posterior slip angle, head-shaft angle (P < 0.05) and epiphyseal height ratio (P < 0.005) in the group using our method were superior to the Southwick group. Postoperative hip motion was nearly the same as the unaffected side. The average leg length discrepancy was 0.9 cm (range, from 0 to 2.0 cm). Reduced blood loss (P < 0.001) and shorter operation time (P < 0.001) were also noted, compared with the Southwick group. We concluded that the intertrochanteric femoral osteotomy based on this strategy minimizes the surgical complexity, resulting in a more anatomic reduction of the capital femoral epiphysis.

PMID 15703514
Abstract/Text The stages in adolescent slipping of the upper femoral epiphysis are classified in relation to treatment. The operation of open replacement of the displaced femoral head is described, and the results of a personal series of seventy-three such operations are presented. Open replacement is excellent treatment for severe chronic slipping so long as the growth plate is still open. The greater incidence of avascular necrosis in acute-on-chronic cases is probably due to damage to the blood supply of the head at the time of the acute slip or kinking of the vessels before replacement. Prolonged traction before operation may increase the risk of chondrolysis. Late onset of osteoarthritis when neither avascular necrosis nor chondrolysis has occurred may be due to misfitting of the articular cartilage because of inaccurate reduction.

PMID 681417
James O Sanders, William J Smith, Earl A Stanley, Matthew J Bueche, Lori A Karol, Henry G Chambers
Progressive slippage after pinning for slipped capital femoral epiphysis.
J Pediatr Orthop. 2002 Mar-Apr;22(2):239-43.
Abstract/Text The authors retrospectively reviewed seven cases of progressive slipped capital femoral epiphysis after screw fixation. All seven patients initially presented with chronic symptoms, and five had an acute exacerbation of symptoms with the appearance of an acute-on-chronic slip. Of the other two, one had obvious motion at the proximal femoral physis and the other had increased symptoms but did not have an obvious acute slip radiographically. All underwent percutaneous screw fixation. In four patients a single screw was placed, and in three patients two screws were placed. No patient became symptom-free after surgery. Slip progression was noted on average 5 months after treatment. Radiographs in all patients revealed an increase in slip severity and loss of screw purchase in the femoral neck while fixation in the proximal femoral epiphysis remained secure. One patient had hypothyroidism and another Cushing disease, both diagnosed after the slipped epiphysis. Slips occurring in children with underlying endocrinopathies, and unstable slips in children with a history of antecedent knee or hip pain (commonly called an acute-on-chronic slip) may be susceptible to screw fixation failure. In such patients, close radiographic follow-up, particularly in the presence of continued symptoms, is required to document slip progression and fixation failure as soon as possible.

PMID 11856939
Ryan C Goodwin, Andrew T Mahar, Timothy S Oswald, Dennis R Wenger
Screw head impingement after in situ fixation in moderate and severe slipped capital femoral epiphysis.
J Pediatr Orthop. 2007 Apr-May;27(3):319-25. doi: 10.1097/BPO.0b013e318032656b.
Abstract/Text In situ stabilization remains the standard of care in the treatment of stable slipped capital femoral epiphysis (SCFE). Screw placement perpendicular to the physis has shown satisfactory results with minimal complications. A prominent screw head may produce femoral acetabular impingement and pain after in situ fixation in severe SCFE. We performed a biomechanical study to establish whether screw head impingement occurs after in situ fixation of SCFE and to define the anatomy of slip severity and screw head position that may lead to impingement. A femoral neck dome osteotomy was created in a human cadaveric model simulating 2 conditions: a moderate and severe SCFEs. We tested the specimens after in situ fixation perpendicular to the simulated physis. The simulated SCFEs and normal control were tested through a full arc of motion. Coverage of the femoral head by the labrum was evaluated at 90 degrees of flexion using fluoroscopy. Impingement occurred at 70 degrees of hip flexion in the simulated moderate SCFE, and at 50 degrees of flexion in the severe simulated SCFE. Anteroposterior fluoroscopy revealed that screw heads lateral to the intertrochanteric line were unlikely to impinge on the acetabulum. Screw head impingement occurred with in situ fixation perpendicular to the physis in simulated moderate and severe SCFEs. Anteroposterior radiographs appear helpful in identifying a hip at risk for screw head impingement after in situ fixation. Alternative in situ fixation techniques (screw head resting lateral to the intertrochanteric line on the anteroposterior radiograph) may decrease the rate of screw head impingement in moderate and severe SCFEs.

PMID 17414018

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