{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,15]],"date-time":"2026-10-15T18:45:50Z","timestamp":1792089950976,"version":"4.4.0"},"reference-count":27,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"4","license":[{"start":{"date-parts":[[2019,1,1]],"date-time":"2019-01-01T00:00:00Z","timestamp":1546300800000},"content-version":"unspecified","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JBJS OA"],"abstract":"<jats:sec>\n                    <jats:title>Background:<\/jats:title>\n                    <jats:p>Recent studies have suggested that the epiphyseal tubercle serves as a fulcrum for rotation in slipped capital femoral epiphysis (SCFE). However, radiographic evidence of the rotational mechanism is limited. In this study, we describe a novel radiographic staging system for SCFE based on the anatomic relationship between the epiphyseal tubercle and the metaphyseal socket.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods:<\/jats:title>\n                    <jats:p>We reviewed the cases of 469 patients with SCFE who were treated at our institution between 2000 and 2017. SCFE was classified according to our proposed staging system using the preoperative lateral radiograph. Normal hips were considered to be Stage 0. In Stage 1, the tubercle is concentric within its metaphyseal socket, which is enlarged and may present peritubercle radiolucency. In Stage 2, there is evidence of eccentricity of the tubercle, which remains in contact with the posterior wall of the socket. In Stage 3, the tubercle and metaphyseal lucency reach the posterior cortex of the femoral neck. A complete dislodgment of the tubercle from the metaphysis is present in Stage 4. Intra- and interobserver agreement, and correlations between the staging system and the traditional classifications of severity, stability, and chronicity, were estimated.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results:<\/jats:title>\n                    <jats:p>The distribution by stage was as follows: 2% of the hips were classified as Stage 0, 19% were Stage 1, 48% were Stage 2, 15% were Stage 3, and 16% were Stage 4. The staging system had excellent intraobserver (\u03ba = 0.89 [95% confidence interval (CI) = 0.83 to 0.96]) and interobserver agreement (\u03ba = 0.87 [95% CI = 0.72 to 1.00]). There was a high correlation between the staging system and SCFE severity as assessed by the Southwick angle (r = 0.77 [95% CI = 0.73 to 0.82]; p &lt; 0.001). There was a moderate correlation between the staging system and the Loder classification of stability (r = 0.55 [95% CI = 0.48 to 0.62]; p &lt; 0.001) and a negligible correlation with the classification of chronicity (r = 0.19 [95% CI = 0.10 to 0.28]; p &lt; 0.001).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions:<\/jats:title>\n                    <jats:p>The proposed staging system for SCFE is highly reliable and correlates well with the severity of SCFE based on the degree of displacement, with moderate correlation shown for stability. This new staging system helps in understanding the rotational mechanism of SCFE, warranting further investigation to determine its clinical application.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Clinical Relevance:<\/jats:title>\n                    <jats:p>The novel classification has the potential for the identification of hips that demonstrate subtle SCFE or are at pre-slip stage, or those at risk for osteonecrosis of the femoral head, failure of fixation, or slip progression.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.2106\/jbjs.oa.19.00033","type":"journal-article","created":{"date-parts":[[2019,11,8]],"date-time":"2019-11-08T15:24:49Z","timestamp":1573226689000},"page":"e0033","source":"Crossref","is-referenced-by-count":14,"title":["A Novel Classification System for Slipped Capital Femoral Epiphysis Based on the Radiographic Relationship of the Epiphyseal Tubercle and the Metaphyseal Socket"],"prefix":"10.2106","volume":"4","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-3893-0292","authenticated-orcid":false,"given":"Daniel A.","family":"Maranho","sequence":"first","affiliation":[{"name":"Departments of Orthopedic Surgery (D.A.M., P.M., and E.N.N.) and Radiology (S.B.), Boston Children\u2019s Hospital, Boston, Massachusetts"},{"name":"Hospital S\u00edrio-Liban\u00eas, Bras\u00edlia, Brazil"},{"name":"Ribeir\u00e3o Preto Medical School, University of S\u00e3o Paulo, Ribeir\u00e3o Preto, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6271-6085","authenticated-orcid":false,"given":"Sarah","family":"Bixby","sequence":"additional","affiliation":[{"name":"Departments of Orthopedic Surgery (D.A.M., P.M., and E.N.N.) and Radiology (S.B.), Boston Children\u2019s Hospital, Boston, Massachusetts"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0141-717X","authenticated-orcid":false,"given":"Patricia E.","family":"Miller","sequence":"additional","affiliation":[{"name":"Departments of Orthopedic Surgery (D.A.M., P.M., and E.N.N.) and Radiology (S.B.), Boston Children\u2019s Hospital, Boston, Massachusetts"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9187-3100","authenticated-orcid":false,"given":"Eduardo N.","family":"Novais","sequence":"additional","affiliation":[{"name":"Departments of Orthopedic Surgery (D.A.M., P.M., and E.N.N.) and Radiology (S.B.), Boston Children\u2019s Hospital, Boston, Massachusetts"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"276","published-online":{"date-parts":[[2019]]},"reference":[{"key":"R1-20231211","first-page":"555","article-title":"Slipped capital femoral epiphysis","volume":"50","author":"Loder","year":"2001","journal-title":"Instr Course Lect"},{"issue":"1","key":"R2-20231211","doi-asserted-by":"crossref","first-page":"94","DOI":"10.2106\/00004623-197658010-00017","article-title":"Shear strength of the human femoral capital epiphyseal plate","volume":"58","author":"Chung","year":"1976","journal-title":"J Bone Joint Surg Am"},{"issue":"2","key":"R4-20231211","doi-asserted-by":"crossref","first-page":"214","DOI":"10.1002\/jor.1100170210","article-title":"Shear strength of the physis varies with anatomic location and is a function of modulus, inclination, and thickness","volume":"17","author":"Williams","year":"1999","journal-title":"J Orthop Res"},{"issue":"12","key":"R5-20231211","doi-asserted-by":"crossref","first-page":"2513","DOI":"10.1007\/s00264-012-1699-y","article-title":"Shape of growth plate of proximal femur in children and its significance in the aetiology of slipped capital femoral epiphysis","volume":"36","author":"Kandzierski","year":"2012","journal-title":"Int Orthop"},{"issue":"1","key":"R6-20231211","doi-asserted-by":"crossref","first-page":"4","DOI":"10.1186\/s40634-014-0004-y","article-title":"Strength of the porcine proximal femoral epiphyseal plate: the effect of different loading directions and the role of the perichondrial fibrocartilaginous complex and epiphyseal tubercle - an experimental biomechanical study","volume":"1","author":"J\u00f3nasson","year":"2014","journal-title":"J Exp Orthop"},{"issue":"6","key":"R7-20231211","doi-asserted-by":"crossref","first-page":"2325967118781579","DOI":"10.1177\/2325967118781579","article-title":"Age- and sex-specific morphologic variations of capital femoral epiphysis growth in children and adolescents without hip disorders","volume":"6","author":"Novais","year":"2018","journal-title":"Orthop J Sports Med"},{"issue":"4","key":"R8-20231211","doi-asserted-by":"crossref","first-page":"416","DOI":"10.3109\/17453670903153550","article-title":"The epiphyseal tubercle in adolescent hips","volume":"80","author":"Tayton","year":"2009","journal-title":"Acta Orthop"},{"issue":"6","key":"R9-20231211","doi-asserted-by":"crossref","first-page":"e341","DOI":"10.2106\/JBJS.L.00474","article-title":"An anatomic study of the epiphyseal tubercle and its importance in the pathogenesis of slipped capital femoral epiphysis","volume":"95","author":"Liu","year":"2013","journal-title":"J Bone Joint Surg Am"},{"issue":"10","key":"R10-20231211","doi-asserted-by":"crossref","first-page":"1402","DOI":"10.1302\/0301-620X.89B10.19563","article-title":"Does the upper femoral epiphysis slip or rotate?","volume":"89","author":"Tayton","year":"2007","journal-title":"J Bone Joint Surg Br"},{"issue":"3","key":"R11-20231211","doi-asserted-by":"crossref","first-page":"239","DOI":"10.1097\/BPO.0000000000000438","article-title":"Validity and clinical consequences of a rotational mechanism for slipped capital femoral epiphysis","volume":"36","author":"Liu","year":"2016","journal-title":"J Pediatr Orthop"},{"issue":"7","key":"R12-20231211","doi-asserted-by":"crossref","first-page":"1571","DOI":"10.1002\/jor.24278","article-title":"Relative contribution of epiphyseal tubercle and peripheral cupping to capital femoral epiphysis stability during daily activities","volume":"37","author":"Kiapour","year":"2019","journal-title":"J Orthop Res"},{"issue":"7","key":"R13-20231211","doi-asserted-by":"crossref","first-page":"e371","DOI":"10.1097\/BPO.0000000000001198","article-title":"The peritubercle lucency sign is a common and early radiographic finding in slipped capital femoral epiphysis","volume":"38","author":"Maranho","year":"2018","journal-title":"J Pediatr Orthop"},{"issue":"5","key":"R14-20231211","doi-asserted-by":"crossref","first-page":"807","DOI":"10.2106\/00004623-196749050-00001","article-title":"Osteotomy through the lesser trochanter for slipped capital femoral epiphysis","volume":"49","author":"Southwick","year":"1967","journal-title":"J Bone Joint Surg Am"},{"issue":"8","key":"R15-20231211","doi-asserted-by":"crossref","first-page":"1134","DOI":"10.2106\/00004623-199308000-00002","article-title":"Acute slipped capital femoral epiphysis: the importance of physeal stability","volume":"75","author":"Loder","year":"1993","journal-title":"J Bone Joint Surg Am"},{"issue":"1","key":"R16-20231211","doi-asserted-by":"crossref","first-page":"62","DOI":"10.2106\/00004623-197759010-00010","article-title":"Remodeling of the femoral neck after in situ pinning for slipped capital femoral epiphysis","volume":"59","author":"O\u2019Brien","year":"1977","journal-title":"J Bone Joint Surg Am"},{"issue":"4","key":"R17-20231211","doi-asserted-by":"crossref","first-page":"244","DOI":"10.1097\/01.bpb.0000111042.46580.68","article-title":"Southwick\u2019s head-shaft angles: normal standards and abnormal values observed in obesity and in patients with epiphysiolysis","volume":"13","author":"Santili","year":"2004","journal-title":"J Pediatr Orthop B"},{"issue":"5","key":"R18-20231211","doi-asserted-by":"crossref","first-page":"378","DOI":"10.1037\/h0031619","article-title":"Measuring nominal scale agreement among many raters","volume":"76","author":"Fleiss","year":"1971","journal-title":"Psychol Bull"},{"issue":"1","key":"R19-20231211","doi-asserted-by":"crossref","first-page":"159","DOI":"10.2307\/2529310","article-title":"The measurement of observer agreement for categorical data","volume":"33","author":"Landis","year":"1977","journal-title":"Biometrics"},{"key":"R21-20231211","first-page":"58","article-title":"The relationship of epiphysial plates to stress in some bones of the lower limb","volume":"96","author":"Smith","year":"1962","journal-title":"J Anat"},{"issue":"4","key":"R22-20231211","doi-asserted-by":"crossref","first-page":"385","DOI":"10.1097\/01241398-198807000-00001","article-title":"Mechanical factors in slipped capital femoral epiphysis","volume":"8","author":"Pritchett","year":"1988","journal-title":"J Pediatr Orthop"},{"key":"R23-20231211","first-page":"1","article-title":"Slipped capital femoral epiphysis. 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A case report","volume":"75","author":"Denton","year":"1993","journal-title":"J Bone Joint Surg Am"},{"issue":"2","key":"R26-20231211","doi-asserted-by":"crossref","first-page":"239","DOI":"10.1097\/01241398-200203000-00022","article-title":"Progressive slippage after pinning for slipped capital femoral epiphysis","volume":"22","author":"Sanders","year":"2002","journal-title":"J Pediatr Orthop"},{"issue":"5","key":"R27-20231211","doi-asserted-by":"crossref","first-page":"601","DOI":"10.1097\/01.bpo.0000230328.06460.be","article-title":"Biomechanical stability of single-screw versus two-screw fixation of an unstable slipped capital femoral epiphysis model: effect of screw position in the femoral neck","volume":"26","author":"Kishan","year":"2006","journal-title":"J Pediatr Orthop"},{"issue":"4","key":"R28-20231211","doi-asserted-by":"crossref","first-page":"479","DOI":"10.1097\/01.bpo.0000226285.46943.ea","article-title":"Biomechanical analysis of in situ single versus double screw fixation in a nonreduced slipped capital femoral epiphysis model","volume":"26","author":"Segal","year":"2006","journal-title":"J Pediatr Orthop"},{"issue":"5","key":"R29-20231211","doi-asserted-by":"crossref","first-page":"496","DOI":"10.1097\/BPO.0000000000000311","article-title":"Biomechanical testing of unstable slipped capital femoral epiphysis screw fixation: worth the risk of a second screw?","volume":"35","author":"Schmitz","year":"2015","journal-title":"J Pediatr Orthop"}],"container-title":["JBJS Open Access"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.ovid.com\/10.2106\/JBJS.OA.19.00033","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,26]],"date-time":"2026-08-26T13:38:53Z","timestamp":1787751533000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.ovid.com\/10.2106\/JBJS.OA.19.00033"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2019]]},"references-count":27,"journal-issue":{"issue":"4","published-online":{"date-parts":[[2019]]}},"URL":"https:\/\/doi.org\/10.2106\/jbjs.oa.19.00033","relation":{},"ISSN":["2472-7245"],"issn-type":[{"value":"2472-7245","type":"electronic"}],"subject":[],"published":{"date-parts":[[2019]]}}}