Clinical consensus recommendations for the non-surgical treatment of children with Perthes' disease in the UK

Aims

The aim of this study was to produce clinical consensus recommendations about the non-surgical treatment of children with Perthes' disease. The recommendations are intended to support clinical practice in a condition for which there is no robust evidence to guide optimal care.

Methods

A two-round, modified Delphi study was conducted online. An advisory group of children's orthopaedic specialists consisting of physiotherapists, surgeons, and clinical nurse specialists designed a survey. In the first round, participants also had the opportunity to suggest new statements. The survey included statements related to 'Exercises', 'Physical activity', 'Education/information sharing', 'Input from other services', and 'Monitoring assessments'. The survey was shared with clinicians who regularly treat children with Perthes' disease in the UK using clinically relevant specialist groups and social media. A predetermined threshold of ≥ 75% for consensus was used for recommendation, with a threshold of between 70% and 75% being considered as 'points to consider'.

Results

A total of 40 participants took part in the first round, of whom 31 completed the second round. A total of 87 statements were generated by the advisory group and included in the first round, at the end of which 31 achieved consensus and were removed from the survey, and an additional four statements were generated. A total of 60 statements were included in the second round and 45 achieved the threshold for consensus from both rounds, with three achieving the threshold for 'points to consider'. The recommendations predominantly included self-management, particularly relating to advice about exercise and education for children with Perthes' disease and their families.

Conclusion

Children's orthopaedic specialists have reached consensus on recommendations for non-surgical treatment in Perthes' disease. These statements will support decisions made in clinical practice and act as a foundation to support clinicians in the absence of robust evidence. The dissemination of these findings and the best way of delivering this care needs careful consideration, which we will continue to explore.

Legg-Calvé-Perthes Disease: Diagnosis, Decision Making, and Outcome

ABSTRACT

Legg-Calvé-Perthes disease (LCPD), or idiopathic avascular necrosis of the proximal capital femoral epiphysis in children, has a variable presentation and can result in significant femoral head deformity that can lead to long-term functional deficits. Plain radiographic imaging is crucial in diagnosing LCPD and guiding treatment. Although the etiology of LCPD remains unknown, the evolution of the disease has been well characterized to include the phases of ischemia, revascularization, and reossification. The mechanical weakening during these phases of healing place the femoral head at high risk of deformity. Treatment of LCPD, therefore, focuses on minimizing deformity through operative and nonoperative strategies to reduce the risk of premature osteoarthritis. Advanced imaging using perfusion MRI may refine surgical decision making in the future, and biological treatments to improve femoral head healing are on the horizon.

The quality of online information on Legg-Calvé-Perthes disease: can we do better?

INTRODUCTION

As patients increasingly utilize the Internet to obtain health-related information, the accuracy and usability of information prove critical, especially for patients and parents seeking care for relatively common orthopedic childhood disorders such as Legg-Calvé-Perthes (LCP) disease. Therefore, the purpose of this study is to evaluate available online health information regarding LCP disease. The study specifically seeks to (1) examine the accessibility, usability, reliability, and readability of online information, (2) compare the quality of sites from different sources, and (3) determine whether Health on the Net Foundation Code (HON-code) certification guarantees higher quality of information.

MATERIALS AND METHODS

Websites from a query of both Google and Bing were compiled and scored using the Minervalidation tool (LIDA), an appraisal tool quantifying website quality, along with the Flesch-Kinkaid (FK) analysis, a metric assessing readability of content. All sites were organized based on source category [academic, private physician/physician group, governmental/non-profit organization (NPO), commercial, and unspecified] and HON-code certification.

RESULTS

Physician-based and governmental/NPO sites had the highest accessibility, the unspecified site group were the most reliable and usable, and the physician-based group was found to require the least education to comprehend. Unspecified sites had a significantly higher rating of reliability than physician sites (p = 0.0164) and academic sites (p < 0.0001). HON-code-certified sites were found to have greater scores across quality domains along with being easier to read compared to sites without certification, with significantly higher reliability scoring (p < 0.0001).

CONCLUSIONS

As a whole, information on the Internet regarding LCP disease is of poor quality. However, our findings also encourage patients to utilize HON-code-certified websites due to their significantly higher reliability. Future studies should analyze methods of improving this publicly available information. Additionally, future analyses should examine methods for patients to better identify reliable websites, as well as the best mediums for optimized patient access and comprehension.

Recommendations for physiotherapy and physical activity for children with Legg-Calvé-Perthes disease: a survey of pediatric orthopedic surgeons and physiotherapists in Sweden

BACKGROUND AND PURPOSE

Physiotherapy, restrictions of physical activity, and weightbearing are part of the treatment of children with Legg-Calvé-Perthes disease (LCPD). Prescription practices are widely discussed and vary between pediatric orthopedic surgeons (POSs) and physiotherapists (PTs). The purpose of this study was to identify recommendations for treatment methods in clinical practice to find some consensus and elaborate guidelines.

PATIENTS AND METHODS

A web-based questionnaire including 3 cases of LCPD (initial, fragmentation, and reossification stages) was answered by 25 POSs and 19 PTs. They were asked to describe their preferred recommendations for physiotherapy, including stretching, strengthening, weightbearing, and physical activities in relation to, e.g., range of motion (ROM) pain, sex, and disease stage.

RESULTS

ROM was considered to be important when recommending physiotherapy; PTs also recognized pain and disease stage. Sex was reported as a factor with low importance. Stretching exercises were recommended for all disease stages. Recommendations for strengthening exercises varied for the initial and fragmentation stages. None of the participants recommended total non-weightbearing. Most restricted trampolining, running, ball sports, and gymnastics in the first 2 stages of the disease and allowed swimming, short walks, cycling, and horse riding without restrictions for all stages.

CONCLUSION

We found high agreement on recommending stretching exercises for all disease stages, but controversies regarding recommendations for strengthening exercises in the initial and fragmentation stages. No non-weightbearing treatment for the affected hip was recommended by any participants at any stage of the disease. There was no clear consensus regarding the appropriate timeline for resuming full activities.

Radiographical and clinical results of a new conservative treatment algorithm in Legg-Calvè-Perthes disease: A retrospective study

Objective:

This study aimed to establish a feasible conservative treatment algorithm for Legg-Calvè-Perthes Disease (LCPD), clarify its limitations, and evaluate the correlations between radiographical and clinical results.

Methods:

Patients diagnosed with LCPD and treated conservatively were evaluated retrospectively; 39 hips from 35 patients were included. The treatment protocol consisted of intermittent manual traction, range of motion exercises, activity limitation, bed rest, NSAID (ibuprofen 100mg/5mL), and ASA (100mg/day) during attack periods. The treatment protocol was standardized, and an algorithm was established for all the patients.

Results:

The mean follow-up was 13.7 (range = 8-22) years. According to the Stulberg classification, 26 (67%) hips were good, 6 (15,3%) were fair, and 7 (17%) were poor. No activity-limiting pain was detected in any patient. The mean Harris score was 90.5 ± 5.3 for Stulberg type 1, 2, and 3 hips, but 84.2 ± 8.8 for Stulberg type 4 and 5 hips. When the patients were evaluated in terms of pain, activity, and function, it was seen that pain and activity were not different, especially in the Stulberg 1, 2, 3, and 4 patients during the mid-term follow-up. The function was the main factor correlating with the Stulberg classification. Twenty-nine (82.8%) families defined the applicability of the treatment protocol as “easy,” 4 (10.3%) defined it as “moderate,” and 2 (6.2%) defined it as “difficult.”

Conclusion:

The present study demonstrated that the treatment protocol was successful and easily applicable to LCPD. Although lateral pillar classification was efficient to predict radiographic results, the Stulberg classification was not correlated with the clinical results for every subgroup.

Level of Evidence:

Level IV, Therapeutic Study

Moderate Weightbearing Restrictions Are Associated with Worse Depressive Symptoms and Anxiety in Children Aged 5 to 7 Years with Perthes Disease

BACKGROUND

Perthes disease most commonly affects children 5 to 7 years old, and nonoperative management, such as weightbearing and activity restrictions, is generally recommended. In earlier research in children aged 8 to 14 years who had Perthes disease, we found that the restrictions were associated with worse mobility, but mental health or social health measures were not linked. However, Perthes disease most commonly affects children 5 to 7 years old who are more emotionally and cognitively immature. Children in this age group are beginning school and organized sports experiences while developing meaningful social relationships for the first time. Because of such different life experiences, it is important to understand the psychosocial consequences of weightbearing and activity restrictions on this specific age group, as they may help guide choices about weightbearing restrictions and mental health support.

QUESTIONS/PURPOSES

In patients aged 5 to 7 years with Perthes disease, we asked: (1) Are weightbearing and activity restrictions associated with worse mental health, evaluated with the Patient-reported Outcome Measurement Information System (PROMIS) depressive symptoms, anxiety, and anger questionnaires? (2) Are weightbearing and activity restrictions associated with worse social health (PROMIS peer relationships measure)? (3) Are weightbearing and activity restrictions associated with worse physical health measures (PROMIS mobility, pain interference, and fatigue measures)? (4) What other factors are associated with mental, social, and physical health measures in these patients?

METHODS

Data were collected from 97 patients with a diagnosis of Perthes disease. Inclusion criteria were age 5 to 7 years at the time the PROMIS was completed, English-speaking patients and parents, in the active stage of Perthes disease (Waldenstrom Stages I, II, or III) who were recommended weightbearing and activity restrictions because of worsening hip pain, poor hip ROM, femoral head deformity, as a postoperative regimen, or if there was substantial femoral head involvement on MRI [23]. Based on their weightbearing and activity restriction regimen, patients were categorized into one of four activity restriction groups (no, mild, moderate, and severe restriction). The following pediatric parent-proxy PROMIS measures were obtained: depressive symptoms, anxiety, anger, peer relationships, mobility, pain interference, and fatigue. We excluded five patients who did not meet the inclusion criteria. Of the remaining 92 patients, 21 were in the no restriction group, 21 were in the mild restriction group, 28 were in the moderate restriction group, and 22 were in the severe restriction group at the time of PROMIS administration. ANOVA was used to compare differences between the mean PROMIS T-scores of these four groups. T-scores are computed from PROMIS survey responses, and a T-score of 50 represents the age-appropriate mean of the US population with an SD of 10. A higher T-score means more of that measure is being experienced and a lower score means less of that measure is being experienced. To address the possibility of confounding variables such as Waldenstrom stage, gender, age at diagnosis, and history of major surgery, we performed a multivariable analysis to compare the association of different weightbearing regimens and the seven PROMIS measures. This allowed us to answer the question of whether weightbearing and activity restrictions are associated with worse physical, mental, and social health measures in Perthes patients aged 5 to 7 years, while minimizing the possible confounding of the variables listed above.

RESULTS

After controlling for confounding variables such as Waldenstrom stage, gender, age at diagnosis, and history of major surgery, we found that moderate activity restriction was associated with worse depressive symptoms (β regression coefficient = 6 [95% CI 0.3 to 12]; p = 0.04) and anxiety (β = 8 [95% CI 1 to 15]; p = 0.02) T-scores than no restrictions. The mild (β = -7 [95% CI -12 to -1]; p = 0.02), moderate (β = -15 [95% CI -20 to -10]; p < 0.001), and severe (β = -23 [95% CI -28 to -18]; p < 0.001), restriction groups had worse mobility T-scores than the no restriction group. Weightbearing and activity restrictions were not associated with anger, peer relationships, pain interference, and fatigue measures. Waldenstrom Stage II disease was associated with worse pain interference than Waldenstrom Stage III (β = 7 [95% CI 0.4 to 13]; p = 0.04). A history of major surgery was associated with worse anger scores (β = 18 [95% CI 3 to 33]; p = 0.02). The child's gender and age at diagnosis had no association with any of the seven PROMIS measures.

CONCLUSION

Moderate weightbearing and activity restrictions are associated with worse depressive symptoms and anxiety in patients with Perthes disease aged 5 to 7 years, after controlling for Waldenstrom stage, gender, age at the time of diagnosis, and history of surgery. Considering the discoveries in this study and in our previous study, for patients 5 to 7 years old, we recommend that providers discuss the potential for mental health changes with moderate weightbearing restrictions with patients and their families. Furthermore, providers should monitor for worsening mental health symptoms at each follow-up visit and refer patients to a clinical child psychologist for support when appropriate. Future studies are needed to assess the effects of these restrictions on mental health over time and after patients are allowed to return to normal activities.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Weightbearing and Activity Restriction Treatments and Quality of Life in Patients with Perthes Disease

BACKGROUND

Weightbearing and activity restrictions are commonly prescribed during the active stages of Perthes disease. These restrictions, ranging from cast or brace treatment with nonweightbearing to full weightbearing with activity restrictions, may have a substantial influence on the physical, mental, and social health of a child. However, their impact on the patient's quality of life is not well-described.

QUESTIONS/PURPOSES

After controlling for confounding variables, we asked (1) are restrictions on weightbearing and activity associated with physical health measures (as expressed by the Patient-Reported Outcome Measurement Information System [PROMIS] mobility, PROMIS pain interference, and PROMIS fatigue) of children in the active stages of Perthes disease? (2) Are these restrictions associated with poorer scores for mental health measures (PROMIS depressive symptoms and PROMIS anxiety)? (3) Are these restrictions associated with poorer scores for social health measures (PROMIS peer relationships)?

METHODS

Between 2013 and 2020, 211 patients with Perthes disease at a single institution were assigned six PROMIS measures to assess physical, mental, and social health. Patients who met the following eligibility criteria were analyzed: age 8 to 14 years old, completion of six PROMIS measures, English-speaking, and active stage of Perthes disease (Waldenstrom Stage I, II, or III). Weightbearing and activity restrictions were clinically recommended to patients in the initial through early reossification stages of Perthes disease when patients had increasing pain, loss of hip motion, loss of hip containment, progression of femoral head deformity, increased hip synovitis, and femoral head involvement on MRI or as a postoperative regimen. Patients were categorized into four intervention groups based on weightbearing and activity regimen. We excluded 111 patients who did not meet the inclusion criteria. The following six pediatric self-report PROMIS measures were assessed: mobility, pain interference, fatigue, depressive symptoms, anxiety, and peer relationships. Of the 100 patients, 36 were categorized into the no-restriction regimen, 27 into the mild-restriction regimen, 25 into the moderate-restriction regimen, and 12 into the severe-restriction regimen at the time of PROMIS administration. The median (range) age at diagnosis was 8 years old (range 2 to 13 years). There were 85 boys and 15 girls. Eleven patients had hips in Waldenstrom Stage I, 10 were in Stage II, and 79 were in Stage III. Forty-four patients had hips classified as lateral pillar B and 47 patients as lateral pillar C. Nine patients had not reached the mid-fragmentation stage for appropriate lateral pillar classification by the time they took the PROMIS survey. ANOVA was used to compare differences between the mean PROMIS T-scores of these weightbearing/activity regimens. Results were assessed with a significance of p < 0.05 and adjusted for Waldenstrom stage, gender, age at diagnosis, and history of major surgery using multivariate regression analysis.

RESULTS

After controlling for confounding variables, the mild- (β regression coefficient -15 [95% CI -19 to -10]; p < 0.001), moderate- (β -19 [95% CI -24 to -14]; p < 0.001), and severe- (β -25 [95% CI -30 to -19]; p < 0.001) restriction groups were associated with worse mobility T-scores compared with the no-restriction group, but no association was detected for the pain interference or fatigue measures. Weightbearing and activity restrictions were not associated with mental health measures (depressive symptoms and anxiety). Weightbearing and activity restrictions were not associated with social health measures (peer relationships). Earlier Waldenstrom stage was associated with worse pain interference (β 10 [95% CI 2 to 17]; p = 0.01) and peer relationships scores (β -8 [95% CI -15 to -1]; p = 0.03); female gender was linked with worse depressive symptoms (β 7 [95% CI 2 to 12]; p = 0.005) and peer relationships scores (β -6 [95% CI -12 to 0]; p = 0.04); and earlier age at diagnosis was associated with worse peer relationships scores (β 1 [95% CI 0 to 2]; p = 0.03). History of major surgery had no connection to any of the six PROMIS measures.

CONCLUSION

We found that weightbearing and activity restriction treatments are associated with poorer patient-reported mobility in the active stages of Perthes disease after controlling for Waldenstrom stage, gender, age at diagnosis, and history of surgery. Weightbearing/activity restrictions, however, are not associated with pain interference, fatigue, depressive symptoms, anxiety, and peer relationships. Understanding how these treatments are associated with quality of life in patients with Perthes disease can aid in decision-making for providers, help set expectations for patients and their parents, and provide opportunities for better education and preparation. Because of the chronic nature of Perthes disease, future studies may focus on longitudinal trends in patient-reported outcomes to better understand the overall impact of this disease and its treatment.

LEVEL OF EVIDENCE

Level III, therapeutic study.

METHODS OF TREATMENT OF LEGG-СALVÉ-PERTHES DISEASE (REVIEW)

This Literature Review presents various treatments, including operative and conservative therapies, of Legg - Calvé - Perthes Disease. The problem is relevant because of the prevalence of the disease. The authors presented a review of literature, which managed to classify the main methods of treatment by the principles of action, practical application, and presented the interpretation of the effectiveness of modern research from the point of view of evidence-based medicine.

[Perfusion magnetic resonance imaging in the treatment of Perthes disease]

In this review about perfusion magnetic resonance imaging (pMRI), we consider it to give detailed insight into the distribution of the infarction in the femoral head in the early phase of Perthes disease. The degree of head involvement is closely related to the long-term prognosis, and as early surgical treatment of children with severe head involvement may be beneficial, pMRI is suggested as an examination in older children with early stages of Perthes disease. The use of gadolinium as contrast medium in otherwise healthy children seems safe, but long-term effects are unknown.

Pediatric Orthopaedic Consults From Chiropractic Care

Alternative medicine in pediatrics is expanding, with chiropractic now a common choice for families seeking alternative medical care. Currently, there is sparse information in the literature exploring the role of chiropractic in orthopaedic pathology. The objective of this case series is to present pediatric patients who received treatment from chiropractors and orthopaedic physicians as well as to review the respective existing research. Data collected included chiropractic diagnosis, orthopaedic diagnosis, imaging studies, treatments, and complications. Twenty-three patients were studied. Scoliosis, Legg-Calvé-Perthes disease, developmental dysplasia of the hip, cerebral palsy, skeletal dysplasia, and slipped capital femoral epiphysis were diagnoses included. Children had multiple sessions of chiropractic for management of these conditions. The parents' perception for chiropractic was positive in every case. Delayed referral, misdiagnosis, adverse events from manipulative therapy, and ineffective treatments were observed in the present study. More research is indicated to validate chiropractic in children with orthopaedic pathology. (Journal of Surgical Orthopaedic Advances 27(1):58-63, 2018).

Clinical outcomes of conservative treatment with a non-weight-bearing abduction brace for Legg-Calvé-Perthes disease

BACKGROUND

Treatment with a brace is the first choice as conservative treatment via the containment method for Legg-Calvé-Perthes disease (LCPD). The purpose of this study is to evaluate clinical outcomes and influential factors of conservative treatment with the non-weight-bearing abduction brace for LCPD.

METHODS

One hundred thirty hips in 130 patients were examined in this study. The mean age at onset was 7.0 years (3.3-12.4 years) and the mean follow-up period was 8.4 years (4.1-17.6 years). The extent of necrosis and lateral collapse of the femoral head were evaluated using the Catterall classification and the lateral pillar classification, respectively. Radiological outcome was assessed as good (classes I and II), fair (III), and poor (IV), according to the modified Stulberg classification.

RESULTS

Radiographic outcome at final follow-up was good in 82 hips (63%), fair in 40 hips (31%), and poor in 8 hips (6%). Multinomial logistic regression analysis showed that major influential factors for good outcomes were as follows: age at onset, lateral pillar classification, and Catterall classification. From the receiver operating characteristic curve, the cut-off value for age at onset was 8.4 years old to obtain good outcomes. Hips with Catterall group I and II and lateral pillar group A and B had significantly better results.

CONCLUSION

Patients younger than 8.4 years old at onset with lateral pillar group A or B or Catterall group I or II showed good outcomes with a non-weight-bearing abduction brace for LCPD. These results show that alternative treatment, such as surgery, may be another option for patients who are not included in the above groups.

Importance of Herrings classification in predicting the outcome of aseptic necrosis of the femoral head

AIM

To highlight the importance of values of the ​​Herring's classification in the treatment planning of Legg-Calve-Perthes disease (LCPD).

METHOD

The charts of 14 patients in a period of 4 years (2004-2008) were retrospectively reviewed. Inclusion criteria was unilateral LCPD and contralateral healthy hip. The patients were divided into three Herring groups according to radiographic images (A, B and C). For all patients the acetabulum/head index (AHI) was determined.

RESULTS

The youngest patient was 4.9 years and the oldest 9.11 years; male patients were dominant (male:female 11:3). The right hip side was more affected comparing to the left one (8:6). The distribution of patients in Herring groups was three in the Group A, six in the Group B and five patients in the Group C. The AHI index was lowest in the group C. Patients in the group C were treated surgically.

CONCLUSION

Herrings classification predicts patients with extensive changes and suggests what kind of treatment should be applied.

Legg-Calvé-Perthes disease: an overview with recent literature

The evolving knowledge on Legg-Calvé-Perthes (LCP) demonstrates the utility of studying a rare disease systematically by piecing together the biology and mechanics of this condition and applying clinical observations to improve patient care. As treatments of less common diseases are hard to randomize and study in meaningful numbers, long-term study groups have been created to provide insight into this entity that remains an enigma in many aspects. These studies permit a more evidence-approached guide to prognosis and treatment. Meanwhile, basic science research contributes to our understanding of pathophysiology of the disruption and repair processes that lead to LCP, with the goal of clinical translation. This review of LCP aims to give an overview of the condition, with specific focus on recent literature.

Update in adolescent orthopaedics: discussion of common hip conditions

The study of the adolescent hip has seen major advances over the past decade, with important findings in the pathophysiology and management of adolescent hip conditions coming through the advent and use of improved surgical techniques to treat residual and complex hip deformities. Pediatricians are familiar with slipped capital femoral epiphysis and Legg-Calvé-Perthes disease, but they may not be as familiar with residual deformities related to those conditions that manifest themselves in the adolescent and young adult population. The recently described concept of femoroacetabular impingement has become one of significant interest, with advanced hip arthroscopy techniques developed to treat the condition through a minimally invasive approach. The adolescent hip continues to fascinate pediatric and young adult surgeons, and it is hoped that with long-term studies that the efforts taken today to save these hips from early joint replacement will ultimately keep young patients active with a good quality of life.

Reliability and stability of three common classifications for Legg-Calvé-Perthes disease

BACKGROUND

To predict the course of Legg-Calvé-Perthes disease (LCPD) and select between treatment options in the early stages, it is critical to have a reliable predictive classification.

QUESTIONS/PURPOSES

We examined the reliability and stability of three common classification systems for LCPD.

METHODS

We identified 69 patients with LCPD, who had hip radiographs taken more than twice after the initial presentation with at least a 3-month interval. The Herring lateral pillar, Catterall, and Salter-Thompson classifications were evaluated in terms of reliability and stability. The inter- and intrarater reliability of the classification systems was determined by three orthopaedic surgeons using intraclass correlation coefficients (ICCs). To evaluate the stability of the classification systems, the percentage agreement and ICCs among the initial rating, rating when entering fragmentation, and final rating were used.

RESULTS

The interrater reliability was highest in Herring lateral pillar classification (ICC, 0.885) followed by the Catterall and Salter-Thompson classifications (ICC, 0.802 and 0.702, respectively). The percentage agreement and ICC between the initial and final rating were, respectively, 55% and 0.491 for the Herring classification and 48% and 0.378 for the Catterall classification.

CONCLUSIONS

Our data show the highest reliability of the classification of Herring et al. However, more than 40% of the hip radiographs at the initial presentation, and in particular, most of Herring Group A patients, were upgraded. Therefore, for patients older than 8 years old and graded as Herring Group A initially, surgeons should keep the possibility of surgical treatment in mind.

Biographical sketch: Georg Clemens Perthes, MD (1869-1927)

This biographical sketch on Georg Perthes corresponds to the historic text, The Classic: On Juvenile Arthritis Deformans (1910), available at DOI 10.1007/s11999-012-2433-1.

Pathological gait in children with Legg-Calvé-Perthes disease and proposal for gait modification to decrease the hip joint loading

PURPOSE

Legg-Calvé-Perthes disease (LCP) severely limits the range of hip motion and hinders a normal gait. Loading of the hip joint is a major consideration in LCP treatment. The aim of this study was to evaluate gait patterns in LCP and identify gait modifications to decrease the load on the affected hip.

METHODS

Forty children with unilateral LCP were divided into three groups based on the time base integral of the hip abductor moments during single stance on the affected side acquired during instrumented 3D gait analysis. X-rays of the affected hip were classified according to Herring and Catterall.

RESULTS

Children in the "unloading" group spontaneously adopted a Duchenne-like gait with pelvis elevation, hip abduction and external rotation during single support phase. The "normal-loading" group showed pelvis elevation with a neutral hip position in the frontal plane. In the "overloading" group the pelvis dropped to the swinging limb at the beginning of stance accompanied by prolonged hip adduction. The time base integral of the hip abductor moments during single stance correlated positively with the X-ray classifications of Herring and Catterall, hip abduction angle and age. Older children preferred to walk in hip adduction during single stance, had more impaired hips and tended to overload them.

CONCLUSION

The hip overloading pattern should be avoided in children with LCP. Gait training to unload the hip might become an integral component of conservative treatment in children with LCP.

[The long-term results of brace treatment in Perthes disease]

OBJECTIVES

We evaluated the long-term radiological outcomes of the patients with Perthes disease who were conservatively treated with brace.

PATIENTS AND METHODS

Thirty-three hips of 27 skeletally mature patients (21 males, 6 females; mean age 25.2±3.4 years; range 20 to 32 years) treated with modified Thomas splint were included in this study. The results were evaluated according to the Stulberg classification.

RESULTS

The mean age of the patients was 6.3±2.2 (range 3-12) years at the onset of the disease and the mean follow-up was 18.6±3.2 (range 7.2-24.1) years. According to onset of the disease, good results were obtained for the patients who were less than six-years-old as 77.7%, between 6-9 years old as 84.2%, after nine years old as 40%. However, 100% of the Herring group A hips, 79.2% of the group B hips and 50% of the group C hips were healed with Stulberg class I or II results.

CONCLUSION

We obtained satisfactory results after conservative treatment with Thomas splint in patients who were between 6-9 years old at onset of the disease with Herring group B involvement. It is hard to say whether the good results were stemmed from having good prognosis of these patients, or stemmed from positive effect of using brace on treatment.

[Legg-Calve-Perthes disease. Updated review]

Legg-Calve-Perthes disease affects the development of the child's hip. Although we know that is produced by aseptic necrosis of the femoral head, the cause of such necrosis is really unknown. Conventional radiology does not permit an early diagnosis; for this reason more advanced diagnostic techniques are needed. The timing of the diagnosis determines the degree of impact in the hip and has importance for the type of treatment to be applied, and the possible complications that the patient may develop. The aim of this work is to make the general practitioner aware of this disease and to take it into consideration when examining a child with problems related to the hip, and in order to make a correct differential diagnosis with conditions that have similar symptoms, because the final outcome will depend on how quickly the diagnosis was established and also the treatment.

[Bone disease with pain. Legg-Calvé-Perthes' disease (LCPD)]

Legg-Calvé-Perthes disease (LCPD) is a relatively common disease in pediatric hip disorder. Now the disease is categorized into osteochondrosis. This disease was firstly reported by Legg A.T. (USA) , Calvé J. (France) , and Perthes G.C. (Germany) in 1910. Since then its pathophysiology, clinical and imaging findings, and natural history have been researched, but the true etiology remains unknown, and effective treatment methods for some types of this disease are not constituted. In this issue, its pathophysiology, clinical symptoms, peculiar features of the imaging modalities, and currently acceptable treatments were addressed.

Is conservative treatment really effective for Legg-Calvé-Perthes disease? A critical review of the literature

INTRODUCTION

The treatment of Legg-Calvé-Perthes Disease (LCPD) is controversial and not well defined. This literature review aimed to assess the quality of the evidence available to support the effectiveness of conservative LCPD treatment advocated by orthopaedic surgeons and(or) paediatricians. A secondary aim was to see if conservative treatments really modify the natural history of LCPD.

MATERIALS AND METHODS

The review was performed mainly on the PubMed Database and based on the principles of Evidence Based Practice (EBP). Keywords used were Perthes disease, conservative treatment, containment treatment, review, and weight-relief. EBP is the integration of the best research evidence with clinical expertise and patient values of which there are five different levels of evidence: (1) Randomized Controlled Trials; (2) Prospective Cohort Study; (3) Case Control or Retrospective Cohort Study;(4) Case Series; 5) Expert Opinion or Individual Case Report. Results. Until 20th August 2005 there were 144 articles of clinical relevance about conservative treatment of LCPD: 16.7% of EBP level 5; 50.7% of level 4; 31.9% of level 3; none of level 2; and 0.7% of level 1.

CONCLUSION

The quality of evidence that supports conservative treatment for children with LCPD is not of high quality. There is no scientific evidence that conservative treatments modify LCPD natural history. Containment, no containment and simple symptomatic treatment have comparable effectiveness. Prolonged weight-relief and(or) containment treatments are associated with social and psychological problems.

[The Legg-Calvé-Perthes disease: which assessment? Which therapeutic approach?]

Legg-Calvé-Perthes disease remains indefinite from an etiologic point of view and unforeseable in its evolution. The evolution depends on the extent of epiphyseal involvement and the age of the child. It may safely be stated that the more extensive the epiphyseal involvement, the more compromised is the prognosis. Also the older the child, the more the femoral head remoulding will be limited. Preserving articular mobility and containing the head within the depth of acetabulum constitute the mainstay of treatment aiming for a femoral head as spherical as possible upon completion of growth. At the end of growth spherical or ovoid heads will cause no or few problems, however strongly deformed femoral heads will evolve into early hip arthritis. The early recognition of which hip will profit from which treatment, constitutes the major difficulty of the therapeutic process.

[Bed rest and skin traction for Perthes' disease: review of the literature]

Long-term bed rest with skin traction, which isolates children with Perthes' disease from their social and educative environment, could be considered as incompatible with the ethics of modern therapeutics. Adaptation for home care has been proposed, but remains burdensome. We searched the literature in order to ascertain the real advantages and disadvantages of bed rest with skin traction and to evaluate the statistical value of published results. Considering that poor outcome is the natural course of the disease in 10-20% of patients, and that the number of patients in this group is further divided according to age and treatment, the number of patients in each treatment arm is rarely sufficient to validate any given treatment. For hips with limited abduction, traction does not appear to be warranted. Conversely, traction could be useful if the aim is to modify the natural course of the disease in precise situations, for example for Herring group B and or B/C patients with bone age above 6 years with a stiff hip. In this case, skin traction should not last more than two weeks and, to be considered useful, should achieve 30 degrees abduction documented on the ap view.

Immobilization and hypercalciuria in children

Intermediate-term immobilization may lead to an increase in serum and urinary calcium. In order to test this hypothesis, we evaluated 46 children, 21 with Legg-Calvé-Perthes disease (LCP; 7.2+/-1.8 years old) and 25 with developmental dysplasia of the hip joint (DDH; 10+/-5 months of age), submitted to immobilization for up to 16 weeks. These two conditions require intermediate-term immobilization as treatment modality, and no studies evaluating calcium metabolism in these groups of patients have been conducted. In LCP patients, blood and 24-h urine samples were obtained before the beginning of treatment and after 1, 6, 8, 14 and 16 weeks of immobilization, while in DDH patients, blood and spot urine samples were collected before treatment and after 6 and 14 weeks of treatment. Urinary calcium, creatinine, potassium and sodium as well as serum calcium, phosphorus, parathyroid hormone, creatinine and alkaline phosphatase were determined in those samples. Renal ultrasound was performed before and after treatment. A mean increase of 2.3 times baseline values of urinary calcium was observed in 40% of previously normocalciuric LCP patients after only 1 week of immobilization. Among the DDH children, who had never previously ambulated, there was no significant variation in the urinary calcium excretion. None of the serum parameters changed in either group throughout the study. Urinary stones were not evidenced by renal ultrasound. Therefore, the present data suggested that intermediate-term immobilization led to a transient increase in urinary calcium in 40% of LCP patients. Complications such as urinary stones were not observed. In conclusion, this modality of treatment does not impose an increased risk of urinary stone formation in LCP and DDH patients.

Multicenter study for Legg-Calvé-Perthes disease in Japan

BACKGROUND

The Japanese Pediatric Orthopaedic Association created a project team in 2000 to research pediatric orthopedic disease through a multicenter study. The aim of this study was to collect epidemiological data on Legg-Calvé-Perthes disease (LCPD) in Japan.

METHODS

The following data were collected by a survey: age, sex, date of diagnosis, family history, sports history, affected sites, symptoms, location of pain, Catterall classification, Herring classification, date of treatment initiation, treatment methods, bracing period, and Stulberg classification.

RESULTS

A total of 711 patients with 766 affected hips were seen from January 1, 1993 to December 31, 1995. The average annual incidence of LCPD was 0.9/100 000. The average age at diagnosis was 7 years 1 month (2.3-14.3 years). The male/female ratio of the study population was 6.3 : 1.0. The affected-side ratio (right hip/left hip/both hips) was 5.1 : 6.8 : 1.0. Both hips were affected in 7.7% of this series. By the Stulberg classification there were 211 (69.4%) type I and II patients (of 304 total patients). Six treatment methods for unilateral LCPD were compared, and there were no significant differences in outcome among the six groups. The ordinal logistic regression analysis showed that the Herring classification, age at the time of diagnosis, and the affected side (for unilateral LCPD) were significant predictors. The ordinal logistic regression analysis also showed that operative treatment had a better outcome than conservative treatment, with an odds ratio of 1.872.

CONCLUSIONS

Many containment methods for LCPD have been performed in Japan, and the optimal treatment method for LCPD was not determined in this study. The overall outcome, however, was not worse than that in worldwide reports.

Pediatric Athlete Hip Disorders

Injuries of the hip and pelvis in pediatric athletes are receiving increased attention. The majority of injuries are soft tissue injuries or apophyseal injuries that heal with nonoperative supportive treatment. Unique injury patterns can be seen in patients who have underlying pediatric hip disorders such as slipped capital femoral epiphysis, and Legg-Perthes disease. With the advent of hip arthroscopy and the development of more advanced imaging of the hip through MR arthrography, internal derangements of the hip such as labral tears, loose bodies, and chondral injuries are being diagnosed and treated with increased frequency. This article reviews the more common injuries of the hip and pelvis in pediatric athletes.

Outcomes of new pogo-stick brace for Legg-Calvé-Perthes' disease

In 1992, the authors developed a non-weightbearing unilateral ambulatory hip abduction brace, which was named the new pogo-stick brace for unilateral Legg-Calve -Perthes' disease. The hip abduction angle of the new pogo-stick brace was adjustable 45 degrees . The advantage of this brace was that even in the sitting position, the hip abduction angle was maintained. Twenty patients were treated with unilateral LCPD using the new pogo-stick brace. In the Catterall classification, one patient was classified as group 2, 17 as group 3, two as group 4. In Herring classification, one patient was classified as group A, 17 as group B, two as group C. Ultrasonography was performed to determine containment of the hip joints, and the abduction angle of the new pogo-stick brace was adjusted to get better containment, every 2 months. Mose's and acetabular head index methods were used for radiographic evaluation, and classified into good, fair and poor groups both at the primary healing and at the final follow-up. Total evaluation was defined as worse group between Mose's method and acetabular head index method. The average time from onset of disease to the primary healing was 25 months. The average bracing period was 21 months. The average follow-up period was 94 months. At the final follow-up appointment, patients who were classified into good and fair groups were 85% in Mose's method, 95% in acetabular head index method, 85% in total evaluation. In Stulberg classification, the total number of patients who were classified into classes I and II was 85%. The outcome of the new pogo-stick brace was not worse than that of any other treatment method, and was better than that of other unilateral ambulatory braces.

Lateral and posterior pillar grade changes during the treatment of Perthes disease in older patients using skin traction and range of motion exercises

INTRODUCTION

The lateral pillar (LP) grade changes detected during treatment periods have received a lot of attention recently. Lappin et al. reported LP collapses in 92 of 275 (33%) patients during the treatment, but did not provide information for comparing treatment methods and age of onset of the disease. The purpose of this study was to review radiological changes in LP grade in older patients with Perthes disease during 20 months of treatment with skin traction and ROM exercises. We have also reported any grade changes in the posterior pillar (PP) classification.

MATERIAL AND METHODS

Twenty-one patients with unilateral disease who were 9 years or older at the onset of symptoms had been followed until skeletal maturity.

RESULTS

Out of 21 older patients with Perthes disease, our study had two (9.5%) who experienced LP collapse and two (9.5%) who experienced PP collapse during the first 20 months of treatment. The average time from onset to hospitalization in hips, initially classified as LP group C and PP group C, was significantly longer than in LP and PP groups A and B. The LP collapse in two hips and PP collapse in two hips occurred during months 4-8 of treatment. On the other hand, of the patients allowed to ambulate with the Pogo stick orthosis from months 8 to 12 and without a brace from months 10 to 15, none had a collapse of their LPs or PPs during these periods.

CONCLUSION

Lappin et al. reported that 92 of 275 patients (33%) who were managed conservatively in several hospitals experienced LP collapse during their treatment periods. Our results suggest that older patients with this disease treated with skin traction and ROM exercises rarely suffer a LP collapse, as compared with the Lappin et al. report.

[The prognostic factors in perthes disease]

The purpose of this study was to evaluate the role of selected factors which may play role in the estimation of late result during Perthes disease and which one can be eliminated during treatment period. The study population consisted of 311 patients (50 patients with bilateral disease, 361 hips joint) who had reached skeletal maturity at last follow up. All hips were treated by containment methods (bed rest and traction in abduction, Petri cast, brace, varus osteotomy, Salter osteotomy and shelf acetabuloplasty). Both clinical and radiological parameters (taken during fragmentation stage) were included in our study: gender, age at the onset, hip joint abduction, type of treatment, extend of the femoral head necrosis according to the Herring and Catterall classification, LLD, premature growth plate arrest, ATD and ATD index, lateral acetabulum shape - type I - normal, concave lateral acetabulum margin, type II--flat, horizontal and type III--convex, sloping, femoral head subluxation, femoral head sphericity disturbance according to the Mose, risk factors according to the Catterall, Wiberg angle, Eyre-Brook index. Long-term results were evaluated according to the Stulberg classification and were divided into two groups: good result--Stulberg group 1 or 2 and poor and bad result--Stulberg group 3, 4 or 5. The unilateral and bilateral Perthes disease was estimated separately. The statistical analysis revealed in unilateral Perthes disease that next risk factors may lead to poor or bad late result: age at the onset 9 and more years, group 3 or 4 according to Catterall and group C according to Herring classification, type III lateral acetabulum shape, hip joint abduction less than 10 degrees, premature growth plate arrest, ATD index less than 0.8, femoral head subluxation more than 20%, femoral head sphericity disturbance more than 5mm, Gage sign, calcification laterally to the femoral head (sensitivity 85.0%, specificity 98.7%). Bilateral Perthes disease: age at the onset over 6 years, group 3 or 4 according to Catterall and group C according to Herring classification, hip joint abduction less than 10 degrees and calcification laterally to the femoral head (sensitivity 81.8%, specificity 92.3%). The statistical analysis showed which clinical and radiological factors may play an important role in estimation of late results during Perthes disease. Additionally during fragmentation stage of Perthes disease we have possibility to correct or eliminate some of the risk factors - femoral head subluxation, lateral acetabulum shape and hip joint abduction and improve the late result.

A proposed prognostic formula for Perthes' disease

We retrospectively reviewed 145 patients with unilateral Perthes' disease and compared a quantitative analysis of early radiographic signs with a predicted prognosis at long-term followup. The average age of the patients at followup was 18.7 years (range, 16.2-27.5 years). We used the age at onset and three radiographic factors as independent variables for multiple regression analysis. The final radiographic results were based on a modified Stulberg's classification as the dependent variable. Fifty patients (35%) had a good outcome, 33 patients (23%) had a fair outcome, and 62 patients (42%) had a poor outcome. The most reliable formula in the stepwise multiple regression analysis was calculated as: y = -0.697 + 0.418 (age score) + 0.860 (involvement score) + 0.248 (subluxation score). The radiographic stage at first visit had no influence on the final results. Multifactorial assessment by combination of age at onset and two radiographic factors (epiphyseal involvement and subluxation) was the most reliable for predicting the prognosis. A score of 1.5 points or less predicted a good prognosis and a score of 2.6 or more indicated a poor prognosis.

LEVEL OF EVIDENCE

Prognostic study, Level IV (case series). See the Guidelines for Authors for a complete description of levels of evidence.

Usefulness of epiphyseal quotient measurement on magnetic resonance images for outcome prediction in patients with early-stage Legg-Calve-Perthes disease

To investigate the usefulness of epiphyseal quotient (EQ) measurement for outcome prediction in patients with Legg-Calve-Perthes disease (LCPD), magnetic resonance (MR) imaging was performed in 26 patients with unilateral LCPD within 6 months of the disease onset and subsequently once every 3 months. All the patients were treated conservatively in our institute between 1990 and 1999. The mean follow-up period was 80 months. Clinical outcome was evaluated based on the plain radiograms of the femoral head at the final examination according to Stulberg's classification: the patients whose outcome was class I were regarded as 'excellent' (excellent group), class II as 'good' (good group), and classes III, IV and V as 'poor' (poor group). The excellent group consisted of 10 patients, the good group of 12, and the poor group of four. The EQ measured on MR images (MR-EQ) decreased remarkably in the poor group chronologically, whereas there was no decrease in the excellent group and a slow decrease in the good group. The mean MR-EQ at or before the sixth month (range, 2-6 months; mean, 4.9 months) was 86.2 (range, 76.8-94.8) in the excellent group, 78.3 (57.0-93.4) in the good group, and 67.4 (57.8-74.5) in the poor group (P<0.05 among the three groups). According to our results, because all patients having an MR-EQ at or before the sixth month of 75 or higher were classified in the excellent or good groups, it is thought that the ongoing method of treatment can be continued. On the other hand, since half of the patients having an MR-EQ at or before the sixth month of lower than 75 were classified in the poor group and had a high potential for a poor outcome, it is thought that these patients require strict containment therapy, and altering the surgical procedure could be considered depending on the particular patient. It was thought that the MR-EQ is a useful predictive factor of LCPD prognosis.

A paired study of Perthes’ disease comparing conservative and surgical treatment

We performed a paired study of mature patients with Perthes’ disease to compare the radiological results after treatment between conservatively- and surgically-treated groups. One patient was selected from each group to create the pairs for this study. Each pair was strictly matched for gender, body mass index, age at onset, stage at the first visit, necrotic area and radiological at-risk signs and each was assessed by comparing the values of six radiological measurements.

Eighteen pairs (36 hips) fitted the criteria. The radiological measurements which showed a statistically better result in the surgical groups were Mose’s method, the acetabular-head index and leg-length discrepancy. There were no statistical differences in the slope of the acetabular roof and the articulotrochanteric distance. Four hips in the conservative group were in Stulberg class II, five in class III and nine in class IV. In the surgical group, 13 were in Stulberg class II, four in class III and one in class IV.

We conclude that surgical treatment improved the sphericity of the femoral head and provided greater acetabular cover, but did not reform the acetabular roof.

It was noteworthy that a greater leg-length discrepancy and a smaller articulotrochanteric distance were not seen in the surgical group. Our study suggests that surgical treatment is preferable in patients with severe Perthes’ disease.

Legg-Calve-Perthes disease. Part II: Prospective multicenter study of the effect of treatment on outcome

BACKGROUND

The treatment of Legg-Calve-Perthes disease has been based on uncontrolled retrospective studies with relatively small numbers of patients. This large, controlled, prospective, multicenter study was designed to determine the effect of treatment and other risk factors on the outcome in patients with this disorder.

METHODS

We enrolled 438 patients with 451 affected hips in a prospective multicenter study in which each investigator applied the same treatment method to each of his or her patients. The five treatment groups consisted of no treatment, brace treatment, range-of-motion exercises, femoral osteotomy, and innominate osteotomy. All patients were between 6.0 and 12.0 years of age at the onset of the disease, and none had had prior treatment. Three hundred and forty-five hips in 337 patients were available for follow-up at skeletal maturity. All hips were classified with the modified lateral pillar classification and the system of Stulberg et al.

RESULTS

There were no differences in outcome among the hips with no treatment, those treated with bracing, and those treated with range-of-motion therapy. There were also no differences between the hips treated with a femoral varus osteotomy and those treated with an innominate osteotomy. Treatment did not have a significant effect on children who had a chronologic age of 8.0 years or less or a skeletal age of 6.0 years or less at the onset of the disease. In the lateral pillar B group and B/C border group, the outcomes of surgical treatment were significantly better than those of nonoperative treatment in children over the age of 8.0 years at the onset of the disease (p < or = 0.05). Patients who were 8.0 years old or less at the onset of the disease in lateral pillar group B did equally well with nonoperative and operative treatment. Hips in lateral pillar group C had the least favorable outcomes, with no differences between the operative and nonoperative groups. The lateral pillar classification (p < 0.0001) and the age at the onset of the disease (p = 0.0001) were both strong prognostic factors. Female patients did significantly worse than male patients if they were over the age of 8.0 years at the onset of the disease (p = 0.004).

CONCLUSIONS

The lateral pillar classification and age at the time of onset of the disease strongly correlate with outcome in patients with Legg-Calve-Perthes disease. Patients who are over the age of 8.0 years at the time of onset and have a hip in the lateral pillar B group or B/C border group have a better outcome with surgical treatment than they do with nonoperative treatment. Group-B hips in children who are less than 8.0 years of age at the time of onset have very favorable outcomes unrelated to treatment, whereas group-C hips in children of all ages frequently have poor outcomes, which also appear to be unrelated to treatment.

Nonsurgical Treatment to Regain Hip Abduction Motion in Perthes Disease: A Retrospective Review

The purpose of this study was to document the ability of a nonsurgical program to improve restricted passive hip abduction in children with Perthes disease. Containment as a form of treatment was recommended if passive hip abduction of 30 degrees or more could be achieved. Medical records and radiographs were retrospectively reviewed for 74 children. Age at admission and onset, side, length of stay, and measurement of passive hip abduction at admission/discharge were recorded. The average increase in abduction with the hip extended was 13 degrees. Forty-two children achieved 30 degrees or more of abduction with the hip extended. Average length of stay was 13 days. Management of restricted abduction in an inpatient setting can allow consideration of containment in 61% of children previously not thought to have the required motion.

Comparison between braced and non-braced Legg-Calvé-Perthes-disease patients: a radiological outcome study

Twenty-three hips of 23 Legg-Calvé-Perthes-disease (LCPD) patients treated with abduction orthosis and 28 hips of 25 non-braced LCPD patients were evaluated radiologically retrospectively. The mean age of the brace group was 6.82 years and the mean follow-up was 12.30 years. The mean age and mean follow-up were 7.03 and 17.85 years for non-braced patients, respectively. The hips were evaluated according to lateral pillar classification. There were eight Herring A, 15 Herring B and five Herring C hips in the non-braced patients group; and there were five Herring A, 11 Herring-B and seven Herring C hips in the brace group. The groups were similar in terms of mean age, mean follow-up, sex distribution and lateral pillar grade. Patients' end results were evaluated according to Stulberg classification. All Herring A patients healed with Stulberg class 1 or 2, either braced or non-braced. Fifty-three percent of non-braced hips and 65% of the hips treated with brace healed with satisfactory radiological outcome. There were no significant differences between the groups in terms of end result. The overall results of this study suggest that Herring's lateral pillar classification is a useful system for the prediction of the long-term outcome of the disease and that there was no significant difference between the braced and non-braced patients in terms of radiological end result.

Intraobserver and interobserver reliability of Catterall, Herring, Salter-Thompson and Stulberg classification systems in Perthes disease

OBJECTIVE

To assess the percentage agreement and intraobserver and interobserver reliability among Catterall, Salter-Thompson, Herring and Stulberg classification systems with special reference to the stage of treatment.

METHODS

Anteroposterior and frog-leg radiographs of 10 patients were evaluated by 18 reviewers on two occasions. Each patient had three sets of radiographs of different stages of disease: before treatment, 6-12 months after the initiation of treatment and at least 5 years after the treatment.

RESULTS

Interobserver-intraobserver agreement rates for Catterall (set 1), Salter-Thompson (set 1), Herring (set 1), Catterall (set 2), Herring (set 2) and Stulberg (set 3) were 0.6203-0.6862, 0.6037-0.5758, 0.5955-0.4946, 0.5782-0.3864, 0.3878-0.1133 and 0.7912-0.7733, respectively.

CONCLUSIONS

The results of our study suggest the use of Catterall and Salter-Thompson systems prior to treatment and the Stulberg system at the end of the treatment at skeletal maturity. However, evaluation of the patients during the treatment period is still a dilemma and necessitates a new more reliable classification system.

[Premature femoral head growth plate closure in Perthes' disease]

The study population consisted of 311 patients (50 female and 261 male) who had reached skeletal maturity at last follow up (361 hips). The mean age at the onset of symptoms was 6 years and 10 months (range: 2.5-13 years). All patients were treated by containment methods (bed rest and traction in abduction, brace, Petri cast, varus osteotomy, Salter osteotomy and shelf operation). Premature growth plate closure was estimated according to Bowen (central and lateral). Necrosis of the femoral head was classified according to Herring and Catterall, late results according to Stulberg and Mose and leg length discrepancy on scanograms. Article-trochanter distance (ATD) was estimated according to the Edgren methods. Premature femoral head growth plate closure was found in 61 hips (central--41 and lateral--20). Statistical analysis did not reveal any correlation between the gender and type of treatment and premature growth plate closure. The central pattern of growth plate closure was more often seen to 6 years of age at the onset and the lateral over 9 years of age at the onset (p = 0.0176). Premature growth plate closure was observed more often in Herring group C and Catterall group 4 (p = 0.0001). Disturbances in femoral head sphericity according to Mose increased (except with bilateral Perthes' disease) and ATD decreased in patients with premature growth plate closure. Also premature growth plate closure increased the leg length discrepancy in Perthes' disease. Thirty two (52.5%) hips with abnormal physeal growth were classified into type I or II according to Stulberg classification, 16 (26.2%) into type III and 13 (21.3%) into type IV or V. Premature growth plate closure in Perthes' disease is more common in huge necrosis of the femoral head. The central pattern of growth plate closure is more often in younger children (to 6 years of age) and the lateral in older (over 9 years of age). With abnormal physeal growth the greater trochanter overgrow and ATD decreased, the leg length discrepancy and disturbances in sphericity of the femoral head increased. Premature growth plate closure increased satisfactory and poor results according to Stulberg classification.

Age at onset, extent of necrosis, and containment in Perthes disease. Results at maturity

BACKGROUND

The concept of containment of the femoral head within the acetabulum has been popularised as a principle of treatment in Perthes disease. The results of 30 patients treated for Perthes disease following a predefined scheme based on the containment were analyzed.

METHODS

All children were treated with abduction braces as long as containment was maintained. However, 15 of them required surgery due to failure of containment in the further course of the disease. All children were followed until skeletal maturity.

RESULTS

Within a mean follow-up period of 8 years and 9 months (range 5-13 years), all patients showed good clinical function. On radiographic assessment, 70% of the hips were Stulberg classes I and II, with a good prognosis.

CONCLUSION

Failure of the containment was influenced by age at onset and extent of necrosis. Weight-bearing abduction braces cannot be recommended in children who are 6 years and older and show femoral head involvement of more than 50%.

Treatment of the collapsed femoral head by containment in Legg-Calve-Perthes disease

One hundred ninety-seven patients with unilateral Legg-Calve-Perthes disease (LCPD) were followed-up to skeletal maturity. According to the lateral pillar classification, 142 hips were classified as group B and 55 hips as group C. Radiographs were evaluated for percent of collapse of the femoral head, Waldenstrom stage of disease at diagnosis, Mose sphericity, hinge abduction, lateral acetabular shape, and limb-length discrepancy. The hips were treated either by bedrest and traction in abduction (76), Petrie cast (21), abduction brace (74), or by pelvic or femoral osteotomy (26). One hundred twenty-five hips had less than a 2-mm difference in Mose sphericity at followup. According to the classification of Stulberg et al., 89 hips (45%) were class I, 57 (29%) were class II, 35 (18%) were class III, 12 (6%) were class IV, and 4 (2%) were class V. Analyses revealed statistically significant differences between group B versus group C with regard to the classifications of Stulberg et al. and Mose, lateral acetabular shape, age at onset, and limb-length discrepancy. There was no significant statistical difference with regard to the types of treatment. Containment treatment of a deformed femoral head from LCPD improves the sphericity of the hip and gives 63% satisfactory results according to the Mose classification and 74% satisfactory results according to the Stulberg et al. classification.

[ATD index in Perthes disease]

Authors present an estimation of articulo-trochanteric-distance (ATD) and ATD index in patients with Perthes disease and if there is any correlation between ATD and ATD index and age at the onset, gender, type of treatment, Herring and Stulberg classification. The study population consisted of 242 patients (35 female and 207 male) who had reached skeletal maturity at last follow up. The mean age at the onset of symptoms was 7 years and 4 months. All patients were treated by containment methods (bed rest and traction in abduction, brace, Petri cast, varus osteotomy, Salter osteotomy and shelf operation). ATD was estimated according to the Edgren methods and ATD index was calculated as relation ATD on Perthes site to ATD in normal joint. The late results were classified according to the Stulberg classification. Statistical analysis did not revealed any correlation between the age at the onset, gender and ATD index and ATD during last follow up. Both parameters decreased with poor results according to the Stulberg classifications. ATD index and ATD were statistically significant less after surgical treatment than after non-operative treatment. The same relations were seen between patients with leg length discrepancy (LLD) and without LLD. Patients in Herring group A had statistically significant bigger both parameters than patients in group B, C and patients in Herring group B than C. Articulo-trochanteric-distance and ATD index decreased during follow up and ATD decreased also in normal joint. In our opinion ATD index is a more reliable radiological parameter than ATD. ATD index decreases with bigger necrosis of the femoral head and poor result according to the Stulberg classification. This parameter is an evidence of the dysfunction proximal femoral growth plate in patients with LLD. The most decreased ATD index was observed after surgical treatment. There was no correlation between the age at the onset, gender and ATD index at last follow up.