Risk factors associated with avascular necrosis following unstable slipped capital femoral epiphysis in pediatric patients: A systematic review and meta-analysis

Zihang Xu; Lei Zhu; Laifa Kong; Yuwang Qian; Xin Zhang; Yuchong Feng; Yiming Wu; Tao Shi

doi:10.1371/journal.pone.0329275

Risk factors associated with avascular necrosis following unstable slipped capital femoral epiphysis in pediatric patients: A systematic review and meta-analysis

Zihang Xu
, Lei Zhu
, Laifa Kong
, Yuwang Qian
, Xin Zhang
, Yuchong Feng
, Yiming Wu^*
, Tao Shi^*

^*Corresponding author for this work

Biomedical Sciences

Research output: Contribution to journal › Article › peer-review

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Abstract

BACKGROUND: The risk factors for avascular necrosis (AVN) in patients with unstable slipped capital femoral epiphysis (SCFE) were controversial and multifactorial. This meta-analysis summarizes existing evidence to identify risk factors for AVN.

METHODS: Search strategies followed the recommendations of the Cochrane Collaboration. Electronic searches such as PubMed, Embase, Web of Science, Cochrane were systematically searched for publications concerning risk factors for unstable SCFE from the inception date to October 2024. The RevMan 5.3 software and Stata 17.0 software were used for the meta-analysis. Finally, publication bias and sensitivity analysis were carried out.

RESULTS: This study included 16 articles involving 688 hips. We found that the overall incidence of AVN was 23%. Our research indicated that male gender (OR = 2.37; 95% CI = 1.23 to 4.58, P = 0.01), the moderate and severe slip (OR = 0.09; 95% CI = 0.02 to 0.37, P < 0.001), the acute slip (OR = 3.93; 95% CI = 1.55 to 9.95, P = 0.004), reduction (OR = 0.87; 95% CI = 0.24 to 3.20, P = 0.84) especially closed reduction (OR = 4.33; 95% CI = 1.09 to 17.28, P = 0.04) were important risk factors for postoperative AVN, while age (MD = -0.58;95% CI = -1.34 to 0.18, P = 0.13), the side of hip (OR = 0.89; 95% CI = 0.44 to 1.80, P = 0.74), the number of implants (OR = 0.87; 95% CI = 0.24 to 3.20, P = 0.84), delayed surgery (OR = 0.64; 95% CI = 0.38 to 1.09, P = 0.10) and capsular decompression (OR = 0.80; 95% CI = 0.32 to 1.99, P = 0.63) were not.

CONCLUSIONS: In summary, the pooled incidence of AVN after unstable SCFEs was 23% and the available evidence demonstrated that being male, having a moderate or severe slip (slip angle ≥ 30°), having an acute slip (symptoms ≤ 3 weeks), and undergoing reduction, especially closed reduction, are important risk factors for postoperative AVN.

LEVEL OF EVIDENCE: IV. This study was registered as PROSPERO 2024 CRD42024566661.

Original language	English
Article number	e0329275
Number of pages	14
Journal	PLOS One
Volume	20
Issue number	7
DOIs	https://doi.org/10.1371/journal.pone.0329275
Publication status	Published - 30 Jul 2025

Bibliographical note

Copyright: © 2025 Xu et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Keywords

Humans
Risk Factors
Femur Head Necrosis/etiology
Slipped Capital Femoral Epiphyses/complications
Child
Male
Female
Incidence

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Cite this

@article{15f4cf36ae3749108e2dea6006e1b8c6,

title = "Risk factors associated with avascular necrosis following unstable slipped capital femoral epiphysis in pediatric patients: A systematic review and meta-analysis",

abstract = "BACKGROUND: The risk factors for avascular necrosis (AVN) in patients with unstable slipped capital femoral epiphysis (SCFE) were controversial and multifactorial. This meta-analysis summarizes existing evidence to identify risk factors for AVN.METHODS: Search strategies followed the recommendations of the Cochrane Collaboration. Electronic searches such as PubMed, Embase, Web of Science, Cochrane were systematically searched for publications concerning risk factors for unstable SCFE from the inception date to October 2024. The RevMan 5.3 software and Stata 17.0 software were used for the meta-analysis. Finally, publication bias and sensitivity analysis were carried out.RESULTS: This study included 16 articles involving 688 hips. We found that the overall incidence of AVN was 23\%. Our research indicated that male gender (OR = 2.37; 95\% CI = 1.23 to 4.58, P = 0.01), the moderate and severe slip (OR = 0.09; 95\% CI = 0.02 to 0.37, P < 0.001), the acute slip (OR = 3.93; 95\% CI = 1.55 to 9.95, P = 0.004), reduction (OR = 0.87; 95\% CI = 0.24 to 3.20, P = 0.84) especially closed reduction (OR = 4.33; 95\% CI = 1.09 to 17.28, P = 0.04) were important risk factors for postoperative AVN, while age (MD = -0.58;95\% CI = -1.34 to 0.18, P = 0.13), the side of hip (OR = 0.89; 95\% CI = 0.44 to 1.80, P = 0.74), the number of implants (OR = 0.87; 95\% CI = 0.24 to 3.20, P = 0.84), delayed surgery (OR = 0.64; 95\% CI = 0.38 to 1.09, P = 0.10) and capsular decompression (OR = 0.80; 95\% CI = 0.32 to 1.99, P = 0.63) were not.CONCLUSIONS: In summary, the pooled incidence of AVN after unstable SCFEs was 23\% and the available evidence demonstrated that being male, having a moderate or severe slip (slip angle ≥ 30°), having an acute slip (symptoms ≤ 3 weeks), and undergoing reduction, especially closed reduction, are important risk factors for postoperative AVN.LEVEL OF EVIDENCE: IV. This study was registered as PROSPERO 2024 CRD42024566661.",

keywords = "Humans, Risk Factors, Femur Head Necrosis/etiology, Slipped Capital Femoral Epiphyses/complications, Child, Male, Female, Incidence",

author = "Zihang Xu and Lei Zhu and Laifa Kong and Yuwang Qian and Xin Zhang and Yuchong Feng and Yiming Wu and Tao Shi",

note = "Copyright: {\textcopyright} 2025 Xu et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.",

year = "2025",

month = jul,

day = "30",

doi = "10.1371/journal.pone.0329275",

language = "English",

volume = "20",

journal = "PLOS One",

issn = "1932-6203",

publisher = "Public Library of Science (PLOS)",

number = "7",

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TY - JOUR

T1 - Risk factors associated with avascular necrosis following unstable slipped capital femoral epiphysis in pediatric patients

T2 - A systematic review and meta-analysis

AU - Xu, Zihang

AU - Zhu, Lei

AU - Kong, Laifa

AU - Qian, Yuwang

AU - Zhang, Xin

AU - Feng, Yuchong

AU - Wu, Yiming

AU - Shi, Tao

N1 - Copyright: © 2025 Xu et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

PY - 2025/7/30

Y1 - 2025/7/30

N2 - BACKGROUND: The risk factors for avascular necrosis (AVN) in patients with unstable slipped capital femoral epiphysis (SCFE) were controversial and multifactorial. This meta-analysis summarizes existing evidence to identify risk factors for AVN.METHODS: Search strategies followed the recommendations of the Cochrane Collaboration. Electronic searches such as PubMed, Embase, Web of Science, Cochrane were systematically searched for publications concerning risk factors for unstable SCFE from the inception date to October 2024. The RevMan 5.3 software and Stata 17.0 software were used for the meta-analysis. Finally, publication bias and sensitivity analysis were carried out.RESULTS: This study included 16 articles involving 688 hips. We found that the overall incidence of AVN was 23%. Our research indicated that male gender (OR = 2.37; 95% CI = 1.23 to 4.58, P = 0.01), the moderate and severe slip (OR = 0.09; 95% CI = 0.02 to 0.37, P < 0.001), the acute slip (OR = 3.93; 95% CI = 1.55 to 9.95, P = 0.004), reduction (OR = 0.87; 95% CI = 0.24 to 3.20, P = 0.84) especially closed reduction (OR = 4.33; 95% CI = 1.09 to 17.28, P = 0.04) were important risk factors for postoperative AVN, while age (MD = -0.58;95% CI = -1.34 to 0.18, P = 0.13), the side of hip (OR = 0.89; 95% CI = 0.44 to 1.80, P = 0.74), the number of implants (OR = 0.87; 95% CI = 0.24 to 3.20, P = 0.84), delayed surgery (OR = 0.64; 95% CI = 0.38 to 1.09, P = 0.10) and capsular decompression (OR = 0.80; 95% CI = 0.32 to 1.99, P = 0.63) were not.CONCLUSIONS: In summary, the pooled incidence of AVN after unstable SCFEs was 23% and the available evidence demonstrated that being male, having a moderate or severe slip (slip angle ≥ 30°), having an acute slip (symptoms ≤ 3 weeks), and undergoing reduction, especially closed reduction, are important risk factors for postoperative AVN.LEVEL OF EVIDENCE: IV. This study was registered as PROSPERO 2024 CRD42024566661.

AB - BACKGROUND: The risk factors for avascular necrosis (AVN) in patients with unstable slipped capital femoral epiphysis (SCFE) were controversial and multifactorial. This meta-analysis summarizes existing evidence to identify risk factors for AVN.METHODS: Search strategies followed the recommendations of the Cochrane Collaboration. Electronic searches such as PubMed, Embase, Web of Science, Cochrane were systematically searched for publications concerning risk factors for unstable SCFE from the inception date to October 2024. The RevMan 5.3 software and Stata 17.0 software were used for the meta-analysis. Finally, publication bias and sensitivity analysis were carried out.RESULTS: This study included 16 articles involving 688 hips. We found that the overall incidence of AVN was 23%. Our research indicated that male gender (OR = 2.37; 95% CI = 1.23 to 4.58, P = 0.01), the moderate and severe slip (OR = 0.09; 95% CI = 0.02 to 0.37, P < 0.001), the acute slip (OR = 3.93; 95% CI = 1.55 to 9.95, P = 0.004), reduction (OR = 0.87; 95% CI = 0.24 to 3.20, P = 0.84) especially closed reduction (OR = 4.33; 95% CI = 1.09 to 17.28, P = 0.04) were important risk factors for postoperative AVN, while age (MD = -0.58;95% CI = -1.34 to 0.18, P = 0.13), the side of hip (OR = 0.89; 95% CI = 0.44 to 1.80, P = 0.74), the number of implants (OR = 0.87; 95% CI = 0.24 to 3.20, P = 0.84), delayed surgery (OR = 0.64; 95% CI = 0.38 to 1.09, P = 0.10) and capsular decompression (OR = 0.80; 95% CI = 0.32 to 1.99, P = 0.63) were not.CONCLUSIONS: In summary, the pooled incidence of AVN after unstable SCFEs was 23% and the available evidence demonstrated that being male, having a moderate or severe slip (slip angle ≥ 30°), having an acute slip (symptoms ≤ 3 weeks), and undergoing reduction, especially closed reduction, are important risk factors for postoperative AVN.LEVEL OF EVIDENCE: IV. This study was registered as PROSPERO 2024 CRD42024566661.

KW - Humans

KW - Risk Factors

KW - Femur Head Necrosis/etiology

KW - Slipped Capital Femoral Epiphyses/complications

KW - Child

KW - Male

KW - Female

KW - Incidence

U2 - 10.1371/journal.pone.0329275

DO - 10.1371/journal.pone.0329275

M3 - Article

C2 - 40737348

SN - 1932-6203

VL - 20

JO - PLOS One

JF - PLOS One

IS - 7

M1 - e0329275

ER -

Risk factors associated with avascular necrosis following unstable slipped capital femoral epiphysis in pediatric patients: A systematic review and meta-analysis

Abstract

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