Valgus femoral osteotomy for noncontainable Perthes hips: prognostic factors of remodeling

Legg-Calvé-Perthes disease- surgical treatment options

Legg-Calvé-Perthes disease (LCPD), is a rare avascular osteonecrosis of the proximal femur usually occurring in children between 5 and 10 years of age. The cause of ischemia leading to necrosis of the femoral head remains unknown. The goal of surgical treatment for LCPD is to improve the containment of the femoral head to restore the function of the hip joint and prevent further damage to the femoral head leading to premature hip osteoarthritis. Although a causal therapy is not available, the main aim is to maintain or restore the containment of the affected hip joint. The specific surgical treatment depends on the patient's age at onset, the stage, and severity of the disease. In early stages of the disease, the most common surgical option is a containment-restoring procedure such as femoral varus osteotomy (FVO), Salter's innominate osteotomy (SIO), and triple pelvic osteotomy (TPO). Moderate forms of LCPD show good results after treatment with either FVO or SIO, severe cases are recommended to be treated with FVO combined with either SIO or TPO to provide good outcomes. In later stages with increased damage to the femoral head, surgical options may include non-containment-restoring procedures to help symptom relief or restore anatomical and biomechanical features to a certain extend e.g., femoral valgus extension osteotomy or trochanter apophyseodesis. Due to the complexity of surgical interventions and the challenging nature of LCPD it is essential to consult with an experienced surgeon in pediatric orthopedics to determine the best treatment course for the patient.

Functional adaptation after femoral intertrochanteric valgus osteotomy in Legg-Calvé-Perthes disease

Legg-Calvé-Perthes disease (LCPD) requires individualized treatment in order to regain a functional hip joint. In severe cases, in which a congruent joint cannot be achieved, other options are necessary in order to improve functionality and prevent early osteoarthritis. Therefore, we analysed the clinical and radiologic outcome of 28 patients after valgus osteotomy of the proximal femur (VOF). We examined the range of hip motion, functionality and health-related quality of life (HRQoL) via modified Harris Hip Score (mHHS) and Kidscreen-10. Radiographic analysis contained quantitative and qualitative measurements of hip morphology. In particular, we correlated the results with the change of the pelvic-femoral angle (PFA). PFA was defined as the angle between the anatomical diaphyseal line of the femur and a vertical line through the pelvis. The mean follow-up was 5.5 years. Patients showed high mHHS and good HRQoL postoperatively. An increase in ROM with an improvement of 30.5° abduction and 10.3° internal rotation was evident. PFA correlated with adduction contracture and improved significantly after surgery. In consideration of careful patient selection, VOF showed a positive effect on ROM, pain, HRQoL, radiographic congruence and outcome. We identified the age at surgery and an increasing adduction contracture-objectified by a decreased PFA-as a prognostic factor.

Epidemiology, natural evolution, pathogenesis, clinical spectrum, and management of Legg-Calvé-Perthes

Background

Legg-Calvé-Perthes disease is a self-limiting disorder that develops in children following interruption of the blood supply to the capital femoral epiphysis. This review outlines the current knowledge on the epidemiology, natural evolution, clinical spectrum, and management of the disease.

Methods

The literature pertaining to these aspects of the disease were studied and summarized in this review.

Results

Epidemiological studies suggest that environmental factors contribute to the causation of the disease. Incidence rates monitored over time indicate that the incidence of Legg-Calvé-Perthes disease is declining. The natural evolution followed on sequential plain radiographs enables division of the disease into Stages Ia, Ib, IIa, IIb, IIIa, IIIb, and IV. Reversible deformation of the capital occurs in Stages Ia-IIa simply on standing while irreversible deformation may occur in Stages IIb and IIIa. Treatment of Legg-Calvé-Perthes disease in Stages Ia-IIa aims to prevent the femoral head from getting deformed by containment and avoidance of weight-bearing. In Stages IIb and IIIa, treatment aims to remedy the effects of early irreversible deformation of the femoral head. In Stage IIIb and IV, treatment is directed to correcting the altered shape of the femoral head. The impression that these treatment methods are helpful is based on poor quality evidence.

Conclusion

There is an urgent need to undertake Level I studies to establish the efficacy of currently treatment.

Level of evidence

level V.

Mid-term results of sub-trochanteric valgus osteotomy for symptomatic late stages Legg-Calvé-Perthes disease

BACKGROUND

The treatment of late stages of Legg-Calvé-Perthes disease (LCPD) is controversial. Although the concept of femoral head containment is a well-established technique of treatment, its use remains debatable in the late stages of the disease, as it does not improve symptoms in terms of limb length discrepancy and gait.

AIM

To assess the results of subtrochanteric valgus osteotomy in symptomatic patients with late-stage Perthes disease.

METHODS

From 2000 to 2007, 36 symptomatic patients with late stage of Perthes disease were surgically treated with subtrochanteric valgus osteotomy and followed-up for 8 to 11 years using the IOWA score and range of motion (ROM) variables. The Mose classification was also assessed at the last follow-up to reflect possible remodeling. The patients were 8 years old or older at the time of surgery, in the post-fragmentation stage, and complaining of pain, limited ROM, Trendelenburg gait, and/or abductor weakness.

RESULTS

The preoperative IOWA score (average: 53.3) markedly improved at the 1-year post follow-up period (average: 85.41) and then slightly improved at the last follow-up (average: 89.4) (P value < 0.05). ROM improved, with internal rotation increased on average by 22° (from 10° preoperatively to 32° postoperatively) and abduction increased on average by 15.9° (from 25° preoperatively to 41° postoperatively). The mean Mose deviation of femoral heads was 4.1 mm at the end of the follow-up period. The tests used were the paired t-test and Pearson correlation test, where the level of significance was a P value less than 0.05.

CONCLUSION

Subtrochanteric valgus osteotomy can be a good option for symptomatic relief in patients with late-stage of LCPD.

Surgical Treatments for Legg-Calvé-Perthes Disease: Comprehensive Review

Background

Legg-Calvé-Perthes disease (LCPD) is a common public health problem that usually occurs between the ages of 4 and 8 years, but it can occur between the ages of 2 and 15 years. This condition occurs due to the interruption of blood supply to the femoral head. Up to now, different surgical and nonsurgical treatments, including femoral varus osteotomy, innominate osteotomy, pelvic osteotomies, triple osteotomy, Chiari osteotomy, and shelf acetabuloplasty, have been suggested for noncontainable LCPD hips.

Objective

The aim of this comprehensive review was to investigate the various surgical techniques used for LCPD.

Methods

An advanced electronic search of the English-language literature was performed from October 8 to 14, 2020. The electronic databases PubMed, MEDLINE, Web of Science, Embase, Ovid, and Google scholar were searched using appropriate search terms. A manual search of references also was performed. After retrieving the studies, duplicates were removed, and the remining studies were screened based on the title, abstract, and full text. The quality of the selected articles was assessed, and the required data were extracted from eligible articles.

Results

A total of 22 studies were included in the review. Based on the results of the reviewed studies, there are three main factors that influence the treatment outcomes in patients with Perthes disease. These factors are onset age, femoral head involvement severity, and treatment method. The disease has a poor prognosis in children over 8 years old, but this group of patients can also benefit from advanced surgical methods. In patients aged less than 6 years, the disease has a generally good prognosis, but in those aged between 6 and 8 years, its prognosis is variable. Thus, the need for surgical intervention requires close observation of signs. Once any head signs are observed, dynamic arthrography is beneficial before choosing the treatment approach.

Conclusions

This review provides clinicians with a brief guideline for the treatment of patients with LCPD.

Femoral osteotomy to improve range of motion in residual deformity of perthes disease: A case report

INTRODUCTION

The treatment strategies for residual deformity of Perthes disease are not established.

CASE PRESENTATION

This is a case report of a 15-year-old boy. He developed right Perthes disease (lateral pillar classification group B) when he was 10 years old and underwent varus femoral osteotomy of the right side. At 12 years of age, he developed left Perthes disease (lateral pillar classification group B) and underwent varus femoral osteotomy of the left side. Postoperatively, he was treated with partial weight bearing of the left leg with crutches. At 15 years, range of motion (ROM) of his left hip was markedly limited at 30° flexion, 10° abduction, 70° external rotation, and -20° internal rotation, and he was having difficulty maintaining a sitting position.

DIAGNOSIS

Stulberg group V was noted on plain radiography. Computed tomography (CT) showed collapse of the load-bearing part of the femoral head on the coronal plane, but the ball-shape was maintained in the posterior femoral head on sagittal and transverse sections.

INTERVENSINOS

Valgus-flexion-internal rotation osteotomy was performed to improve ROM.

OUTCOMES

Left hip ROM improved to 90° flexion, 20° abduction, 50° external rotation, and 40° internal rotation immediately after the surgery. He was able to sit 10 months postoperatively but was left with a limp and limited ROM in the left hip at 60° flexion. Chondroplasty was performed during the plate removal surgery at 10 months postoperatively, which improved hip flexion to 100° immediately after the surgery. The patient was left with limited ROM of 60° flexion of the left hip at the final observation.

CONCLUSION

Femoral osteotomy to improve ROM could be an option for residual deformity of Perthes disease.

Short follow-up evaluation of proximal femoral varus osteotomy for treatment of Legg-Calvé-Perthes disease

BACKGROUND

There are many methods of treating Legg-Calvé-Perthes disease, including operative and nonoperative methods. Femoral varus osteotomy is one of the surgical methods used to treat this disease, and it involves changing the alignment of the proximal femur to improve containment of the femoral epiphysis in the acetabulum. The aims of this study were to evaluate the results of femoral varus osteotomy for the treatment of Perthes disease according to various classification and grading schemes, as well as to compare the results to those obtained using other methods of treatment reported in the literature.

MATERIALS AND METHODS

Twenty-three patients with Legg-Calvé-Perthes disease were treated using a proximal femoral varus osteotomy procedure. The mean age of the patients was 7.8 years (range: 6-11.5 years). The average follow-up was 36.2 months (range: 29-48 months).

RESULTS

The patients were classified and graded according to the Catterall and Herring classifications. The preoperative and postoperative mean epiphyseal extrusion indices were as follows: group III (B), 10.88 % and 7.22 %, P = 0.027; group III (BC), 15.81 and 8.93 %, P = 0.005; group IV (C), 72.64 and 39.44 %, P = 0.018. The preoperative and the postoperative mean Wiberg's CE angle were as follows: group III (B), 26.88° and 37.81°, P = 0.028; group III (BC), 24.4° and 32.2°, P = 0.005; group IV (C), 20.89° and 28.41°, P = 0.018. Changes in Iowa clinical hip scores were as follows: group III (B), 54.8 to 92.33, P = 0.027; group III (BC), 47.3 to 87.8, P = 0.005; group IV (C) 34.43 to 68.29, P = 0.017. In the last follow-up, the mean limb length discrepancy after plate removal was 0.9 cm (range: 0.0-2 cm) of shortening on the operated side. The author of the present study did not see any progressive change in this parameter during the follow-up period, especially after hardware removal and in the younger boys. All of the osteotomies united within 3 months without loss of fixation.

CONCLUSION

According to the results of the present study, proximal femoral varus osteotomy gives good results in children between the ages of 6 and 10 years without any femoral head deformity and flattening, especially with good containment in abduction.

LEVEL OF EVIDENCE

Level IV.

What clinimetric evidence exists for using hip-specific patient-reported outcome measures in pediatric hip impingement?

BACKGROUND

Patient-reported outcomes (PROs) are an increasingly popular research tool used to evaluate the outcomes of surgical intervention. If applied appropriately, they can be useful both for disease monitoring and as a method of assessing the efficacy of treatment. Many disorders can lead to impingement in children and adolescents, but it is not clear if any PROs have been validated to evaluate outcomes in these populations.

QUESTIONS/PURPOSES

We performed a systematic review of the literature to answer the following research questions: (1) Which hip-specific PROs are used in pediatric populations with impingement? (2) What clinimetric evidence exists for the use of these specific PROs in this population?

METHODS

We performed two systematic searches of three databases (Medline, EMBASE, and Ovid All EBM Reviews). The first search aimed to identify specific PROs that have been applied to pediatric impingement populations. The second search aimed to find clinimetric evaluations of the PROs from the first search in this population.

RESULTS

We found six hip-specific PROs applied in pediatric impingement: Harris Hip Score, modified Harris Hip Score, Iowa Hip Score, Merle d'Aubigné Hip Score, Hip Outcome Score, and Non-arthritic Hip Score. However, we found no papers validating any of these PROs in this population. Furthermore, we found no papers validating any of these PROs in any pediatric population.

CONCLUSIONS

A number of adult PROs have been applied in pediatric impingement disorders without evidence of validation in any pediatric population. Further work to develop and validate a hip-specific pediatric PRO is required.