How Common Is Femoral Retroversion and How Is it Affected by Different Measurement Methods in Unilateral Slipped Capital Femoral Epiphysis?
Authors: Schmaranzer Florian , Kallini Jennifer R. , Ferrer Mariana G. , Miller Patricia E. , Wylie James D. , Kim Young-Jo , Novais Eduardo N. 
Published: December 2020

Abstract

Background
Although femoral retroversion has been linked to the onset of slipped capital femoral epiphysis (SCFE), and may result from a rotation of the femoral epiphysis around the epiphyseal tubercle leading to femoral retroversion, femoral version has rarely been described in patients with SCFE. Furthermore, the prevalence of actual femoral retroversion and the effect of different measurement methods on femoral version angles has yet to be studied in SCFE.

Questions/purposes
(1) Do femoral version and the prevalence of femoral retroversion differ between hips with SCFE and the asymptomatic contralateral side? (2) How do the mean femoral version angles and the prevalence of femoral retroversion change depending on the measurement method used? (3) What is the interobserver reliability and intraobserver reproducibility of these measurement methods?

Methods
For this retrospective, controlled, single-center study, we reviewed our institutional database for patients who were treated for unilateral SCFE and who had undergone a pelvic CT scan. During the period in question, the general indication for obtaining a CT scan was to define the surgical strategy based on the assessment of deformity severity in patients with newly diagnosed SCFE or with previous in situ fixation. After applying prespecified inclusion and exclusion criteria, we included 79 patients. The mean age was 15 ± 4 years, 48% (38 of 79) of the patients were male, and 56% (44 of 79) were obese (defined as a BMI > 95th percentile (mean BMI 34 ± 9 kg/m2). One radiology resident (6 years of experience) measured femoral version of the entire study group using five different methods. Femoral neck version was measured as the orientation of the femoral neck. Further measurement methods included the femoral head’s center and differed regarding the level of landmarks for the proximal femoral reference axis. From proximal to distal, this included the most-proximal methods (Lee et al. and Reikerås et al.) and most-distal methods (Tomczak et al. and Murphy et al.). Most proximally (Lee et al. method), we used the most cephalic junction of the greater trochanter as the landmark and, most distally, we used the center base of the femoral neck superior to the lesser trochanter (Murphy et al.). The orientation of the distal femoral condyles served as the distal reference axis for all five measurement methods. All five methods were compared side-by-side (involved versus uninvolved hip), and comparisons among all five methods were performed using paired t-tests. The prevalence of femoral retroversion (< 0°) was compared using a chi-square test. A subset of patients was measured twice by the first observer and by a second orthopaedic resident (2 years of experience) to assess intraobserver reproducibility and interobserver reliability; for this assessment, we used intraclass correlation coefficients.

Results
The mean femoral neck version was lower in hips with SCFE than in the contralateral side (-2° ± 13° versus 7° ± 11°; p < 0.001). This yielded a mean side-by side difference of -8° ± 11° (95% CI -11° to -6°; p < 0.001) and a higher prevalence of femoral retroversion in hips with SCFE (58% [95% CI 47% to 69%]; p < 0.001) than on the contralateral side (29% [95% CI 19% to 39%]). These differences between hips with SCFE and the contralateral side were higher and ranged from -17° ± 11° (95% CI -20° to -15°; p < 0.001) based on the method of Tomczak et al. to -22° ± 13° (95% CI -25° to -19°; p < 0.001) according to the method of Murphy et al. The mean overall femoral version angles increased for hips with SCFE using more-distal landmarks compared with more-proximal landmarks. The prevalence of femoral retroversion was higher in hips with SCFE for the proximal methods of Lee et al. and Reikerås et al. (91% [95% CI 85% to 97%] and 84% [95% CI 76% to 92%], respectively) than for the distal measurement methods of Tomczak et al. and Murphy et al. (47% [95% CI 36% to 58%] and 60% [95% CI 49% to 71%], respectively [all p < 0.001]). We detected mean differences ranging from -19° to 4° (all p < 0.005) for 8 of 10 pairwise comparisons in hips with SCFE. Among these, the greatest differences were between the most-proximal methods and the more-distal methods, with a mean difference of -19° ± 7° (95% CI -21° to -18°; p < 0.001), comparing the methods of Lee et al. and Tomczak et al. In hips with SCFE, we found excellent agreement (intraclass correlation coefficient [ICC] > 0.80) for intraobserver reproducibility (reader 1, ICC 0.93 to 0.96) and interobserver reliability (ICC 0.95 to 0.98) for all five measurement methods. Analogously, we found excellent agreement (ICC > 0.80) for intraobserver reproducibility (reader 1, range 0.91 to 0.96) and interobserver reliability (range 0.89 to 0.98) for all five measurement methods in healthy contralateral hips.

Conclusion
We showed that femoral neck version is asymmetrically decreased in unilateral SCFE, and that differences increase when including the femoral head’s center. Thus, to assess the full extent of an SCFE deformity, femoral version measurements should consider the position of the displaced epiphysis. The prevalence of femoral retroversion was high in patients with SCFE and increased when using proximal anatomic landmarks. Since the range of femoral version angles was wide, femoral version cannot be predicted in a given hip and must be assessed individually. Based on these findings, we believe it is worthwhile to add evaluation of femoral version to the diagnostic workup of children with SCFE. Doing so may better inform surgeons as they contemplate when to use isolated offset correction or to perform an additional femoral osteotomy for SCFE correction based on the severity of the slip and the rotational deformity. To facilitate communication among physicians and for the design of future studies, we recommend consistently reporting the applied measurement technique.

Level of Evidence
Level III, prognostic study.