Skip to main content

“Slipped capital femoral epiphysis in a 25-year-old hypogonadic man with a large cranial chondroma: causality or coincidence? “

Abstract

Background

Slipped capital femoral epiphysis (SCFE) is a hip disorder frequently occurring in adolescence. In adults it is rare and so far very few cases have been documented.

Case presentation

This report presents a 25-year-old patient diagnosed with an anterior fossa giant chondroma, hypogonadotropic hypogonadism, and SCFE. The patient underwent surgical and hormonal therapy. His symptoms revealed, and he became a father.

Conclusions

Every patient diagnosed with SCFE in adulthood should undergo endocrinological assessment based on physical examination and laboratory tests.

Peer Review reports

Background

Slipped capital femoral epiphysis (SCFE) is a frequent hip disorder in adolescence, which should be quickly diagnosed and treated. The sub-acute and long-term consequences of SCFE are the loss of joint function and osteoarthritis due to femoroacetabular impingement [1].

SCFE affects about 10.8 in 100,000 people [2]. Despite many theories, its aetiology is still unclear. Incorrect distribution of forces working on the proximal part of the femur, relative and absolute retroversion of the femoral neck are identified as potential mechanical factors which cause SCFE. Obesity [3,4,5], endocrine disorders (hypothyroidism, hypopituitarism, hypoparathyroidism) [5, 6], genetic disorders [7, 8] and growth hormone therapy are potential causes of epiphyseal cartilage injury. Slipped capital femoral epihysis in adults is very rare. So far very few cases have been documented. This article presents a 25-year-old patient diagnosed with an anterior fossa giant chondroma, hypogonadotropic hypogonadism, and SCFE.

Case presentation

So far apparently healthy 25-year-old white male presented to an emergency room with a chief complaint of tonic seizures. The diagnostic imaging (NMR of the head and angio-CT) showed that the man suffered from a large anterior cranial fossa tumour (Fig. 1).

Fig. 1
figure 1

Anterior cranial fossa tumor

The tumor was removed by the fronto-parietal craniotomy. Histopathological examination revealed it was a chondroma. The postoperative period was uneventful.

Three months after the procedure, the patient presented to the emergency room with severe pain in the left hip joint. The ailment characterized as recurrent started about a year ago. A sudden increase in pain intensity occurred six months later and resulted in patient ambulation on crutches to prevent weight bearing on the affected limb. Physical examination revealed the Drehmann’s sign was positive, the left limb in the extension was rotated 45 degrees, all movements at the hip joint were excruciating. There were no vascular and nervous disturbances. The pelvis A-P and Lauenstein’s axial radiography and Computed Tomography of the pelvis were performed (Figs. 2, 3 and 4). Diagnostic imaging has showed bilateral opened epiphyseal cartilages of the femurs and SCFE on the left, affecting lateral and posterior part. The clinical and radiological assessment suggested proceeding with an open joint reconstruction with Dunn’s dislocation description by Ganz [9, 10] (Figs. 5, 6). The following day patient was placed in the upright position, and the rehabilitation started. After two more weeks patient was permitted to partially bear weight on the affected leg. Two months after the operation patient was able to fully bear weight on the affected limb. Three months after the operation patient regained full range of motion and walked without crutches (Table 1, Fig. 7).

Fig. 2
figure 2

XR A/P of the hip

Fig. 3
figure 3

SCFE in transverse plane CT before surgery

Fig. 4
figure 4

Hip CT 3D-reconstruction before surgery

Fig. 5
figure 5

Osteotomy of the greater trochanter

Fig. 6
figure 6

Separation of the head of the femur from the neck

Fig. 7
figure 7

Postoperative hip XR anterior-posterior and axial views

Table 1 Range of motion and X-Ray parameters befora and 3 months after surgery

Endocrinological consultation was suggested due to clinical features of hypogonadism and revealed that the patient was 194 cm tall and his weight was 83 kg (BMI 22.05 kg/m2). His arm span was 197 cm. He presented features of delayed sexual maturation. Examination of external genitalia showed micropenis and testicular volume of 3.3 ml and 3.6 ml in the right and left testes, respectively (Tanner’s stage of 2). To our knowledge, these signs of delayed puberty were firstly observed during an endocrine consultation on SCFE. Laboratory tests revealed hypogonadotropic hypogonadism with no other features of pituitary insufficiency (Table 2). Normal pituitary gland was visualized in NMR. The bone age was 15 years. Dual-energy X-ray absorptiometry was performed, and osteoporosis was found (Z-score at lumbar spine − 3.4). Clinical findings were also reflected in a genetic test. Direct sequencing of gonadotropin-releasing hormone receptor (GNRHR, MIM:138850, ref.: NM_000406.2) revealed compound heterozygosity for two independent mutations R139H and R262Q (each allele is affected by one mutation, Fig. 8). The genetic status of a patient leads to the synthesis of altered GNRHR protein. The patient had a normal male karyotype (46XY), and other chromosomal rearrangements in the genome that could be responsible for the phenotype, were excluded. The treatment with human chorionic gonadotropin (hCG) was initiated two weeks following the surgery to achieve both masculinization and spermatogenesis. The treatment resulted in a complete restoration of phenotype and functional male sex characteristics. The patient became a father of a healthy daughter three years after treatment initiation. The anatomy and function of the operated hip joint are preserved (Fig. 9). Figure 10 presents patient treatment timeline.

Table 2 Serum hormones’ concentration
Fig. 8
figure 8

Direct sequencing of GNRHR gene and compound heterozygosity for R139H (A) and R262Q (B) mutations (depicted by an arrow) detected in patient’s DNA

Fig. 9
figure 9

Postoperative XR axial plane

Fig. 10
figure 10

Patient treatment timeline

Patients’ perspective

I had always felt different. My appearance and even the way I behaved had been very different from most my collegues. After I started the therapy, my body has changed, my mood, even my voice. After several months of the therapy I felt in love for the first time in my life, and I am a happy father of a wonderful girl.”

Discussion and conclusions

Although SCFE is a common disease of the hip joint it creates a big challenge to treat its subsequent deformation from the surgical perspective. Avascular necrosis (AVN) and chondrolysis occur more often in the group of patients operated on than in patients without surgical intervention or only with neck and head osteosynthesis in situ (without reduction of deformation) [11,12,13]. The osteosynthesis of the neck and head in situ causes deformation leading to earlier degenerative changes of the hip joint and results in a femoro-acetabular-impingement. Traditional procedures (e.g. Imhauser’s osteotomy, Southwick’s intertrochanteric osteotomy) are safe; however, correction of deformations only partially improves the joint function. Artrotomy became a safe procedure due to research made at Berne’s school for surgery dislocation of the hip joint [14, 15].

It is worth emphasizing that complete epiphyseal fusion occurs between 16 and 19 years old in European-American males [16]. Since our patient was 25 years old, the delay of bone age = was about 10 years.

Another fact that makes the described case unique is that SCFE mainly occurs in obese patients [3, 4], while our patientBMI was 22.05 kg / m2, which is the desired body weight.

Interesting is also the fact of late diagnosis (when full sexual maturity should have been achieved for several years) of delayed puberty. There is no doubt that this should have been diagnosed much earlier than at 25. We might speculate that the undiagnosed delayed puberty reflects the weakness of the health care system and cultural and social factors influencing an individual reaction to being different.

As was mentioned above, SCFE in adults is extremely rare and is always associated with endocrinopathy. To date, there are very few cases reported of SCFE in adults with panhypopituitarism, hypogonadotrophic hypogonadism, hypothyroidism, acromegaly [17,18,19,20,21,22,23]. Therefore, every patient diagnosed with SCFE in adulthood should undergo endocrinological assessment based on physical examination and laboratory tests. Our patient presented with a genetically caused autosomal recessive GNRH-related hypogonadotropic hypogonadism. It seems that the giant chondroma was an unrelated co-morbidity.

Availability of data and materials

Not applicable.

Abbreviations

SCFE:

Slipped capital femoral epiphysis

FAI:

femoro-acetabular impingement

BMI:

body mass index

MRI:

Magnetic resonance imaging

DEXA:

dual-energy x-ray absorptiometry

hCG:

human chorionic gonadotropin

GNRHR:

gonadotropin-releasing hormone receptor

FSH:

follicle-stimulating hormone

LH:

luteinizing hormone

TSH:

thyroid-stimulating hormone

FT3:

triiodothyronine (thyroid hormones)

FT4:

thyroxine (thyroid hormones)

PRL:

prolactin

ACTH:

adrenocorticotropic hormone

GH:

growth hormone

IGF-1:

insulin-like growth factor 1

ET:

Southwick’s lateral epiphyseal-shaft angle

References

  1. Leunig M, Casillas MM, Hamlet M, Hersche O, Nötzli H, Slongo T, et al. Slipped capital femoral epiphysis: early mechanical damage to the acetabular cartilage by a prominent femoral metaphysis. Acta Orthop Scand. 2000 Aug;71(4):370–5. https://doi.org/10.1080/000164700317393367.

    Article  CAS  PubMed  Google Scholar 

  2. Peck DM, Voss LM, Voss TT. Slipped capital femoral epiphysis: diagnosis and management. Am Fam Physician. 2017 Jun 15;95(12):779–84.

    PubMed  Google Scholar 

  3. Ucpunar H, Camurcu IY, Duman S, Ucpunar E, Sofu H, Bayhan AI. Obesity-related metabolic and endocrine disorders diagnosed during postoperative follow-up of slipped capital femoral epiphysis. Acta Orthop. 2018 May 4;89(3):314–9. https://doi.org/10.1080/17453674.2018.1445167.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Perry DC, Metcalfe D, Lane S, Turner S. Childhood Obesity and Slipped Capital Femoral Epiphysis. Pediatrics. 2018 Nov;142(5).

  5. Swarup I, Goodbody C, Goto R, Sankar WN, Fabricant PD. Risk factors for contralateral slipped capital femoral epiphysis: a meta-analysis of cohort and case-control studies. J Pediatr Orthop. 2020 Jul;40(6):e446–53. https://doi.org/10.1097/BPO.0000000000001482.

    Article  PubMed  Google Scholar 

  6. Loder RT, Wittenberg B, DeSilva G. Slipped capital femoral epiphysis associated with endocrine disorders. J Pediatr Orthop. 1995;15(3):349–56. https://doi.org/10.1097/01241398-199505000-00018.

    Article  CAS  PubMed  Google Scholar 

  7. Acosta AM, Steinman SE, White KK. Orthopaedic manifestations in Turner syndrome. J Am Acad Orthop Surg. 2019 Dec 1;27(23):e1021–8. https://doi.org/10.5435/JAAOS-D-17-00796.

    Article  PubMed  Google Scholar 

  8. Nasrallah MP, Der-Boghossian AH, Haidar RK. Slipped capital femoral epiphysis in a patient with Turner syndrome receiving growth hormone therapy. Endocr Pract Off J Am Coll Endocrinol Am Assoc Clin Endocrinol. 2012;18(6):e135–7.

    Google Scholar 

  9. Ganz R, Gill TJ, Gautier E, Ganz K, Krügel N, Berlemann U. Surgical dislocation of the adult hip a technique with full access to the femoral head and acetabulum without the risk of avascular necrosis. J Bone Joint Surg (Br). 2001;83(8):1119–24. https://doi.org/10.1302/0301-620X.83B8.0831119.

    Article  CAS  Google Scholar 

  10. Masquijo JJ, Allende V, D’Elia M, Miranda G, Fernández CA. Treatment of slipped capital femoral epiphysis with the modified Dunn procedure: a multicenter study. J Pediatr Orthop. 2019 Feb;39(2):71–5. https://doi.org/10.1097/BPO.0000000000000936.

    Article  PubMed  Google Scholar 

  11. Agashe MV, Pinto DA, Vaidya S. Modified Dunn osteotomy for moderate and severe slipped capital femoral epiphysis - a retrospective study of thirty hips. Indian J Orthop. 2021 Feb;55(1):100–8. https://doi.org/10.1007/s43465-020-00156-w.

    Article  PubMed  Google Scholar 

  12. Galletta C, Aprato A, Giachino M, Marre Brunenghi G, Boero S, Turchetto L, et al. Modified Dunn procedure versus percutaneous pinning in moderate/severe stable slipped capital femoral epiphyses. Hip Int J Clin Exp Res Hip Pathol Ther. 2021;8:11207000211004862.

    Google Scholar 

  13. Lerch TD, Vuilleumier S, Schmaranzer F, Ziebarth K, Steppacher SD, Tannast M, et al. Patients with severe slipped capital femoral epiphysis treated by the modified Dunn procedure have low rates of avascular necrosis, good outcomes, and little osteoarthritis at long-term follow-up. Bone Jt J. 2019;101-B(4):403–14. https://doi.org/10.1302/0301-620X.101B4.BJJ-2018-1303.R1.

    Article  CAS  Google Scholar 

  14. Goodman DA, Feighan JE, Smith AD, Latimer B, Buly RL, Cooperman DR. Subclinical slipped capital femoral epiphysis. Relationship to osteoarthrosis of the hip. J Bone Joint Surg Am. 1997;79(10):1489–97. https://doi.org/10.2106/00004623-199710000-00005.

    Article  CAS  PubMed  Google Scholar 

  15. Passaplan C, Gautier L, Gautier E. Long-term follow-up of patients undergoing the modified Dunn procedure for slipped capital femoral epiphysis. Bone Jt Open. 2020 Apr;1(4):80–7. https://doi.org/10.1302/2633-1462.14.BJO-2020-0010.R1.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Crowder C, Austin D. Age ranges of epiphyseal fusion in the distal tibia and fibula of contemporary males and females. J Forensic Sci. 2005 Sep;50(5):1001–7.

    Article  Google Scholar 

  17. Nhamoucha Y, Tazi M, Abdellaoui H, Alaoui O, Andaloussi S, Oukhoya M, et al. Slipped capital femoral epiphysis in a patient with cerebral palsy due to seizure. Pan Afr Med J. 2018;31:89.

    Article  Google Scholar 

  18. Macía-Villa CC, Sanchez-Lite I, Medina-Luezas J. Slipped capital femoral epiphysis in adults: case report and review of literature. Reumatismo. 2016 Jun 23;68(1):40–7. https://doi.org/10.4081/reumatismo.2016.860.

    Article  PubMed  Google Scholar 

  19. Speirs JN, Morris SC, Morrison MJ. Slipped Capital Femoral Epiphysis in an Adult Patient With Kabuki Syndrome. J Am Acad Orthop Surg Glob Res Rev. 2019 Oct;3(10).

  20. Herngren B, Stenmarker M, Vavruch L, Hagglund G. Slipped capital femoral epiphysis: a population-based study. BMC Musculoskelet Disord. 2017 Dec;18(1):304. https://doi.org/10.1186/s12891-017-1665-3.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Kumar G, Mathew V, Kandathil JC, Theruvil B. Primary hyperparathyroidism presenting as slipped capital femoral epiphysis. Postgrad Med J. 2020 Apr;96(1134):235–6. https://doi.org/10.1136/postgradmedj-2019-136811.

    Article  PubMed  Google Scholar 

  22. Al-Aswad BI, Weinger JM, Schneider AB. Slipped capital femoral epiphysis in a 35-year-old man (a case report). Clin Orthop. 1978;134:131–4.

    Google Scholar 

  23. Huang K-C, Hsu RW-W. Slipped capital femoral epiphysis in a 23-year-old man -- a case report. Acta Orthop. 2007;78(5):696–7. https://doi.org/10.1080/17453670710014428.

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

Not applicable.

Funding

Not applicable.

Author information

Authors and Affiliations

Authors

Contributions

NSG, WW, JN, ESP, BB wrote the manuscript; NSG, WW, JN, JK, ESP, MR were involved in patient’s management; BB performed the genetic analysis; MP, MR performed the literature review and revised the manuscript. All authors have read and approved the manuscript.

Corresponding author

Correspondence to Nadia Sawicka-Gutaj.

Ethics declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Sawicka-Gutaj, N., Woźniak, W., Naczk, J. et al. “Slipped capital femoral epiphysis in a 25-year-old hypogonadic man with a large cranial chondroma: causality or coincidence? “. BMC Endocr Disord 21, 167 (2021). https://doi.org/10.1186/s12902-021-00828-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s12902-021-00828-0

Keywords