The seasonality of slipped upper femoral epiphysis--meta-analysis: a possible association with vitamin D.

We performed a meta-analysis of studies evaluating the seasonality of slipped upper femoral epiphysis (SUFE). In addition we compared the monthly incidences of SUFE at latitudes greater than 40° with the established serum 25-hydroxyvitamin levels for children resident at a comparative latitude. In total 11 relevant studies were identified, involving 7451 cases of SUFE. There was significant variation in the month of onset of SUFE. The degree of variability increased with increasing latitude. The modal month of symptomatic onset was dependent upon latitude. At latitudes greater than 40°, the most common month of onset was August. At latitudes between 20° and 40°, this was earlier in the calendar year, around April. The seasonal variability was statistically significant (p<0.0001 and p<0.005 for latitudes >40° and 20°-40° respectively). The pattern of monthly fluctuation in onset of SUFE very closely mirrored the monthly pattern of variation for serum 25-hydroxyvitamin D3. There was a very strong positive correlation (Spearman rank rho = + 0.8, p = 0.001). There is a monthly variation in incidence of SUFE. The degree of variability increases with increasing latitude. There may be an association with vitamin D. We hypothesise that elevated serum 25-hydroxyvitamin D3 accelerates growth thus rendering the growth plate vulnerable to slippage in analogous manner to the pubertal growth spurt.

Epiphysiolysis of the hip: relationship between etiopathogenesis and hormone status.

The authors present a review of the literature on the etiology of epiphysiolysis of the hip and an original study on the hormone status of these patients. By examining eleven values including hormones, vector proteins, and hormonal transport, the authors related the data obtained to the anagraphical age of the patient, to his or her skeletal age, to the development of sexual features, and to the radiologic evidence of pathology. In light of the results obtained, despite the fact that the study only included 23 patients, the modified equilibrium between SHBG and Somatomedin C, would seem to lead to an accelerated turnover in the growth plate. The increase in BMI directly correlated with low levels of SHBG is also an indication of the increase in body weight that certainly contributes to slippage of the femoral head.

Serum insulin-like growth factors IGF-I and IGFBP-3 in children with slipped capital femoral epiphysis.

Hormonal imbalance in puberty and biomechanical overload due to obesity have been implied in the still unknown cause of slipped capital femoral epiphysis (SCFE). Local mediators of growth hormone (GH) action, such as insulin-like growth factor I (IGF-I), play a crucial role in the development of the growth plate cartilage. Concentrations of IGF-I and its binding protein 3 (IGFBP-3) were measured in the serum of 19 SCFE children without endocrine disorders. Standing height and body weight were determined. The results were related to the bone age. Concentrations for IGF-I and IGFBP-3 were predominantly within the normal ranges for chronologic age and bone age. The correlation of IGF-I and IGFBP-3 serum levels was high. Standing height and body weight showed a tendency toward the higher percentile ranges. Ten of 19 patients were above the 97th percentile concerning their weight for height. Bone age did not differ significantly from chronologic age. Serum concentrations of IGF-I and IGFBP-3 provided no evidence of a disturbance of the somatotropic axis in SCFE children. Increased body weight associated with normal skeletal maturation implies a mechanical stress factor in the cause of SCFE in these children.

Deficiency of a parathyroid hormone fragment containing the midportion and 1,25-dihydroxyvitamin D in serum of patients with slipped capital femoral epiphysis.

The endocrine abnormality that causes slipped capital femoral epiphysis (SCFE) has not been revealed. Recent studies have shown that parathyroid hormone (PTH) and 1,25-dihydroxyvitamin D [1,25-(OH)2D] are involved in growth-plate chondrogenesis and matrix mineralization. Thus we examined in 13 patients with SCFE the serum levels of three immunoreactive forms of PTH (iPTH): the whole peptide [(1-84)PTH], the fragment containing the COOH-terminal portion (C-PTH), and the midportion (M-PTH). Additionally, serum levels of 25-hydroxyvitamin D [25-(OH)D] and 1,25-(OH)2D were measured. We found that the levels of M-PTH were significantly lower than those of controls, whereas levels of C-PTH and (1-84)PTH were not significantly different from those of controls. Similarly, levels of 1,25-(OH)2D were also significantly lower than control levels. In patients with initially low levels of M-PTH and 1,25-(OH)2D in whom the levels were monitored over a period, all levels returned to normal within a year after the onset of disease. The deficiency of M-PTH or 1,25-(OH)2D during the growth spurt could result in SCFE, although in this study, we cannot deny the possibility that the slippage may cause the deficiency.

[Hip diseases and growth hormone deficiency]. / Maladies de hanche et déficit en hormone de croissance.

Five cases of hip disease (3 Perthes disease, 2 slipped capital femoral epiphyses) occurring in growth hormone deficient children are described. Relationships with the endocrine deficiency and its treatment are discussed. Growth hormone treatment does not appear to be a causative factor.

Maturation factors in slipped capital femoral epiphysis.

Several maturation factors relative to growth and epiphyseal development were reviewed retrospectively in 191 patients with slipped capital femoral epiphysis, including bone age, height and weight, thyroid functions, sex hormone levels, and growth hormone levels. Seventy-one percent of 138 patients had weights above the 80th percentile. Active thyroid (T3) was significantly low in 25% of 80 patients studied. Testosterone levels were markedly depressed in 76% of 64 patients tested. In this same group, 87% had low growth hormone levels. The consistently low testosterone and growth hormone levels, along with a tendency toward hypothyroidism, lend support to the biochemical theory of a delicate hormonal imbalance in slipped capital femoral epiphysis.

Thyroid hormone levels in patients with slipped capital femoral epiphysis.

Twelve patients with slipped capital femoral epiphysis and 12 age- and sex-matched controls were prospectively studied. Their height, weight, skeletal maturation, and thyroid status were assessed. The duration of symptoms and severity of the slip was recorded in the test group. There was no correlation between duration of symptoms and severity of the slip or delay in making the diagnosis and severity. Although 50 percent of patients with slipped capital femoral epiphysis were over the 90th percentile for weight, there was no overall significant difference in weight, height, or skeletal maturation between the two groups. There was no evidence of either overt or subclinical hypothyroidism in patients with slipped capital femoral epiphysis.

[Management of slipped epiphyses in renal osteodystrophy (author's transl)]. / Therapeutische Erfahrungen bei urämischer Epiphysenlösung

Epiphyseal slipping in uraemia differs strikingly from juvenile epiphyseal slipping with respect to pathology and therapy. Based on our own experience with the treatment of 8 uraemic children with epiphyseal slipping, an effort was made to establish the respective indications for conservative and surgical treatment. Mechanical stabilization of slipped epiphyses was achieved within a few weeks without any surgery and usually without parathyreoidectomy by vitamin D3 alone. The initial dose was 10,000 to 30,000 I.U./day, the total curative dose 1.8 to 5.6 millions I.U. Prolonged immobilization was unnecessary. Rising urinary calcium excretion was a valuable indicator of vitamin D intoxication even in advanced renal failure. In one case, pronounced metaphyseal deformations (distal femur, distal tibia) required surgical correction before the ability to walk normally was restored. - The following therapeutical approach is recommended: metabolic bone disease must be cured by vitamin D therapy with or without parathyreoidectomy. Osteotomy to correct metaphyseal deformities or coxa vara epiphysaria never should be performed before metabolic bone disease is healed.