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Abstract
Current knowledge of the causes and risk factors of Legg-Calvé-Perthesdisease (LCPD) does not allow effective preventive strategies. The outcome in adulthood is usually good. Hip osteoarthritis rarely develops before 50 years of age. The risk of osteoarthrosis depends chiefly on the final degree of joint incongruence. Age at onset and the lateral pillar classification are the two main outcome predictors and serve to guide the surgical indications based on the studies by Herring's group. Non-operative treatment is not effective. In contrast, femoral varus osteotomy and Salter's innominate osteotomy provide good outcomes. In severe forms, however, combining these two techniques or performing a triple pelvic osteotomy seem preferable. Surgery is now performed considerably less often than in the past, as it is effective only in patients with lateral pillar group B or B/C disease with onset after eight years of age. In other situations, therapeutic abstention is recommended.
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Affiliation(s)
- J Leroux
- Clinique chirurgicale infantile, hôpital Charles-Nicolle, centre hospitalier universitaire (CHU) de Rouen, 1, rue de Germont, Rouen 76031, France.
| | - S Abu Amara
- Clinique chirurgicale infantile, hôpital Charles-Nicolle, centre hospitalier universitaire (CHU) de Rouen, 1, rue de Germont, Rouen 76031, France
| | - J Lechevallier
- Clinique chirurgicale infantile, hôpital Charles-Nicolle, centre hospitalier universitaire (CHU) de Rouen, 1, rue de Germont, Rouen 76031, France
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Abstract
Orthopedic injuries in children are unique when compared to those of adults because of the physiologic differences, especially the growth plates, stronger periosteum, and dynamic state of growth. The approach to the orthopedically injured child requires a gentle yet thorough focus with consideration of the growth plates as a primary area of weakness and growth when the child sustains an injury. Understanding the developmental stages of bones is paramount to being able to manage any injuries. Finally, what appears to be a benign injury may portend more serious issues, because nonaccidental trauma must always be considered in the evaluation of the injured child.
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Affiliation(s)
- Matthew D Thornton
- Department of Emergency Medicine, Bay State Medical Center, 759 Chestnut Street, Springfield, MA 01199, USA
| | - Karen Della-Giustina
- Department of Emergency Medicine, Bridgeport Hospital, 267 Grant Street, Bridgeport, CT 06610, USA.
| | - Paul L Aronson
- Department of Pediatric Emergency Medicine, Yale New Haven Childrens Hospital, 100 York Street, Suite 1F, New Haven, CT 06511, USA
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Kim HKW, Wiesman KD, Kulkarni V, Burgess J, Chen E, Brabham C, Ikram H, Du J, Lu A, Kulkarni AV, Dempsey M, Herring JA. Perfusion MRI in Early Stage of Legg-Calvé-Perthes Disease to Predict Lateral Pillar Involvement: A Preliminary Study. J Bone Joint Surg Am 2014; 96:1152-1160. [PMID: 25031369 DOI: 10.2106/jbjs.m.01221] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Current radiographic classifications for Legg-Calvé-Perthes disease cannot be applied at the early stages of the disease. The purpose of this study was to quantify the perfusion of the femoral epiphysis in the early stages of Legg-Calvé-Perthes disease with use of perfusion magnetic resonance imaging (MRI) and to determine if the extent of epiphyseal perfusion can predict the lateral pillar involvement at the mid-fragmentation stage. METHODS Twenty-nine patients had gadolinium-enhanced perfusion MRI at the initial stage or early fragmentation stage of Legg-Calvé-Perthes disease and were followed prospectively. The percent perfusion of the whole epiphysis and its lateral third was measured by four independent observers using image analysis software. The radiographs obtained at the mid-fragmentation stage were used for the lateral pillar classification. Intraclass correlation coefficient (ICC) and logistic regression analyses were performed. RESULTS The mean age (and standard deviation) at diagnosis was 7.7 ± 1.7 years (range, 5.3 to 11.3 years). The mean interval between the MRI and the time of maximum fragmentation was 8.2 ± 5.5 months. The interobserver ICC for the percent perfusion of the lateral third of the epiphysis was 0.90 (95% confidence interval [CI]: 0.83 to 0.95). The mean percent perfusion of the lateral third of the epiphysis was 92% ± 2%, 68% ± 18%, and 46% ± 12% for the hips in which the lateral pillar was later classified as A, B, and C, respectively (p = 0.001). When the perfusion level was ≥90% in the lateral third of the epiphysis, the odds ratio of the lateral pillar being later classified as group A, as opposed to B or C, was 72.0 (CI: 3.5 to 1476). With a perfusion level of ≤55% in the lateral third of the epiphysis, the odds ratio of the lateral pillar being later classified as group C, as opposed to A or B, was 33.3 (CI: 2.8 to 392). Similar results were obtained for the whole epiphysis. CONCLUSIONS Perfusion MRI measurements of the total epiphysis and its lateral third obtained at the early stages of Legg-Calvé-Perthes disease were predictive of lateral pillar involvement at the mid-fragmentation stage of the disease. LEVEL OF EVIDENCE Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Harry K W Kim
- Center of Excellence in Hip Disorders (H.K.W.K., K.D.W., V.K., J.B., E.C., C.B., H.I., J.D., A.L., and J.A.H.) and Department of Radiology (M.D.), Texas Scottish Rite Hospital for Children, 2222 Welborn Street, Dallas, TX 75219. E-mail address for H.K.W. Kim:
| | - Kathryn D Wiesman
- Center of Excellence in Hip Disorders (H.K.W.K., K.D.W., V.K., J.B., E.C., C.B., H.I., J.D., A.L., and J.A.H.) and Department of Radiology (M.D.), Texas Scottish Rite Hospital for Children, 2222 Welborn Street, Dallas, TX 75219. E-mail address for H.K.W. Kim:
| | - Vedant Kulkarni
- Center of Excellence in Hip Disorders (H.K.W.K., K.D.W., V.K., J.B., E.C., C.B., H.I., J.D., A.L., and J.A.H.) and Department of Radiology (M.D.), Texas Scottish Rite Hospital for Children, 2222 Welborn Street, Dallas, TX 75219. E-mail address for H.K.W. Kim:
| | - Jamie Burgess
- Center of Excellence in Hip Disorders (H.K.W.K., K.D.W., V.K., J.B., E.C., C.B., H.I., J.D., A.L., and J.A.H.) and Department of Radiology (M.D.), Texas Scottish Rite Hospital for Children, 2222 Welborn Street, Dallas, TX 75219. E-mail address for H.K.W. Kim:
| | - Elena Chen
- Center of Excellence in Hip Disorders (H.K.W.K., K.D.W., V.K., J.B., E.C., C.B., H.I., J.D., A.L., and J.A.H.) and Department of Radiology (M.D.), Texas Scottish Rite Hospital for Children, 2222 Welborn Street, Dallas, TX 75219. E-mail address for H.K.W. Kim:
| | - Case Brabham
- Center of Excellence in Hip Disorders (H.K.W.K., K.D.W., V.K., J.B., E.C., C.B., H.I., J.D., A.L., and J.A.H.) and Department of Radiology (M.D.), Texas Scottish Rite Hospital for Children, 2222 Welborn Street, Dallas, TX 75219. E-mail address for H.K.W. Kim:
| | - Haseeb Ikram
- Center of Excellence in Hip Disorders (H.K.W.K., K.D.W., V.K., J.B., E.C., C.B., H.I., J.D., A.L., and J.A.H.) and Department of Radiology (M.D.), Texas Scottish Rite Hospital for Children, 2222 Welborn Street, Dallas, TX 75219. E-mail address for H.K.W. Kim:
| | - Jerry Du
- Center of Excellence in Hip Disorders (H.K.W.K., K.D.W., V.K., J.B., E.C., C.B., H.I., J.D., A.L., and J.A.H.) and Department of Radiology (M.D.), Texas Scottish Rite Hospital for Children, 2222 Welborn Street, Dallas, TX 75219. E-mail address for H.K.W. Kim:
| | - Amanda Lu
- Center of Excellence in Hip Disorders (H.K.W.K., K.D.W., V.K., J.B., E.C., C.B., H.I., J.D., A.L., and J.A.H.) and Department of Radiology (M.D.), Texas Scottish Rite Hospital for Children, 2222 Welborn Street, Dallas, TX 75219. E-mail address for H.K.W. Kim:
| | | | - Molly Dempsey
- Center of Excellence in Hip Disorders (H.K.W.K., K.D.W., V.K., J.B., E.C., C.B., H.I., J.D., A.L., and J.A.H.) and Department of Radiology (M.D.), Texas Scottish Rite Hospital for Children, 2222 Welborn Street, Dallas, TX 75219. E-mail address for H.K.W. Kim:
| | - J Anthony Herring
- Center of Excellence in Hip Disorders (H.K.W.K., K.D.W., V.K., J.B., E.C., C.B., H.I., J.D., A.L., and J.A.H.) and Department of Radiology (M.D.), Texas Scottish Rite Hospital for Children, 2222 Welborn Street, Dallas, TX 75219. E-mail address for H.K.W. Kim:
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Lobert PF, Dillman JR, Strouse PJ, Hernandez RJ. Unexpected MRI findings in clinically suspected Legg-Calvé-Perthes disease. Pediatr Radiol 2011; 41:369-73. [PMID: 20865410 DOI: 10.1007/s00247-010-1841-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2010] [Revised: 08/21/2010] [Accepted: 09/01/2010] [Indexed: 11/28/2022]
Abstract
BACKGROUND In the setting of clinically suspected Legg-Calvé-Perthes (LCP) disease and negative/equivocal radiographs, contrast-enhanced MRI can be performed to confirm the diagnosis. OBJECTIVE To determine the frequency of unexpected causes of hip pain as identified by MRI in children with clinically suspected LCP disease and negative/equivocal radiographs. MATERIALS AND METHODS All pediatric contrast-enhanced MRI examinations of the pelvis and hips performed between January 2000 and February 2009 to evaluate for possible LCP disease in the setting of negative/equivocal radiographs were identified. MRI examinations performed to evaluate for secondary avascular necrosis were excluded. Imaging reports were retrospectively reviewed for unexpected clinically important causes of hip pain. RESULTS Thirty-six pediatric patients underwent contrast-enhanced MRI examinations for clinically suspected LCP disease in the setting of negative/equivocal radiographs. Twenty-two (61%) imaging studies were normal, while four (11%) imaging studies demonstrated findings consistent with LCP disease. Ten (28%) imaging studies revealed unexpected clinically important causes of hip pain, including nonspecific unilateral joint effusion and synovitis (n=7, juvenile chronic arthritis was eventually diagnosed in 3 patients), sacral fracture (n=1), apophyseal injury (n=1), and femoral head subluxation (n=1). CONCLUSION MRI frequently reveals unexpected clinically important causes of hip pain in children with suspected LCP disease and negative/equivocal radiographs.
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Affiliation(s)
- Philip F Lobert
- Department of Radiology, Section of Pediatric Radiology, C.S. Mott Children's Hospital/F3503, University of Michigan Health System, 1500 E. Medical Center Drive, Ann Arbor, MI 48109-5252, USA
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