Arthroscopic Femoral Head Allograft With Proximal Femoral/Periacetabular Osteotomies for Sequelae of Perthes: A Case Report.

CASE: We describe the unique case of a 20-year-old man with a history of Legg-Calve-Perthes disease, hip dysplasia, and osteochondral fragmentation of the medial femoral head. We performed arthroscopic femoroplasty and femoral head allografting, followed by a valgus-producing derotational femoral osteotomy (DFO) and periacetabular osteotomy (PAO). At 1-year follow-up, the patient achieved osseous union and complete femoral head healing with return to his active hobbies. CONCLUSION: We describe the successful utilization of arthroscopic allografting for medial femoral head osteochondral fragmentation. To our knowledge, this is the first report on femoral head arthroscopic allografting before DFO and PAO.

Ganz femoral head reduction associated with coverage and containment procedures improve radiological and functional outcomes in Perthes' disease.

Aims: Ganz's studies made it possible to address joint deformities on both the femoral and acetabular side brought about by Perthes' disease. Femoral head reduction osteotomy (FHRO) was developed to improve joint congruency, along with periacetabular osteotomy (PAO), which may enhance coverage and containment. The purpose of this study is to show the clinical and morphological outcomes of the technique and the use of an implemented planning approach. Methods: From September 2015 to December 2021, 13 FHROs were performed on 11 patients for Perthes' disease in two centres. Of these, 11 hips had an associated PAO. A specific CT- and MRI-based protocol for virtual simulation of the corrections was developed. Outcomes were assessed with radiological parameters (sphericity index, extrusion index, integrity of the Shenton's line, lateral centre-edge angle (LCEA), Tönnis angle), and clinical parameters (range of motion, visual analogue scale (VAS) for pain, Merle d'Aubigné-Postel score, modified Harris Hip Score (mHHS), and EuroQol five-dimension five-level health questionnaire (EQ-5D-5L)). Early and late complications were reported. Results: The mean follow-up was 39.7 months (standard deviation (SD) 26.4). The mean age at surgery was 11.4 years (SD 1.6). No major complications were recorded. One patient required a total hip arthroplasty. Mean femoral head sphericity increased from 46.8% (SD 9.34%) to 70.2% (SD 15.44; p < 0.001); mean LCEA from 19.2° (SD 9.03°) to 44° (SD 10.27°; p < 0.001); mean extrusion index from 37.8 (SD 8.70) to 7.5 (SD 9.28; p < 0.001); and mean Tönnis angle from 16.5° (SD 12.35°) to 4.8° (SD 4.05°; p = 0.100). The mean VAS improved from 3.55 (SD 3.05) to 1.22 (1.72; p = 0.06); mean Merle d'Aubigné-Postel score from 14.55 (SD 1.74) to 16 (SD 1.6; p = 0.01); and mean mHHS from 60.6 (SD 18.06) to 81 (SD 6.63; p = 0.021). The EQ-5D-5L also showed significant improvements. Conclusion: FHRO associated with periacetabular procedures is a safe technique that showed improved functional, clinical, and morphological outcomes in Perthes' disease. The newly introduced simulation and planning algorithm may help to further refine the technique.

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.

Fully automatic system to detect and segment the proximal femur in pelvic radiographic images for Legg-Calvé-Perthes disease.

This study aimed to develop a method using computer vision techniques to accurately detect and delineate the proximal femur in radiographs of Legg-Calvé-Perthes disease (LCPD) patients. Currently, evaluating femoral head deformity, a crucial predictor of LCPD outcomes, relies on unreliable categorical and qualitative classifications. To address this limitation, we employed the pretrained object detection model YOLOv5 to detect the proximal femur on over 2000 radiographs, including images of shoulders and chests, to enhance robustness and generalizability. Subsequently, we utilized the U-Net convolutional neural network architecture for image segmentation of the proximal femur in more than 800 manually annotated images of stage IV LCPD. The results demonstrate outstanding performance, with the object detection model achieving high accuracy (mean average precision of 0.99) and the segmentation model attaining an accuracy score of 91%, dice coefficient of 0.75, and binary IoU score of 0.85 on the held-out test set. The proposed fully automatic proximal femur detection and segmentation system offers a promising approach to accurately detect and delineate the proximal femoral bone contour in radiographic images, which is essential for further image analysis in LCPD patients. Clinical significance: This study highlights the potential of computer vision techniques for enhancing the reliability of Legg-Calvé-Perthes disease staging and outcome prediction.

Intravoxel incoherent motion (IVIM) detects femoral head ischemia in a piglet model of Legg-Calvé-Perthes disease.

There is a clinical need for alternatives to gadolinium contrast-enhanced magnetic resonance imaging (MRI) to facilitate early detection and assessment of femoral head ischemia in pediatric patients with Legg-Calvé-Perthes disease (LCPD), a juvenile form of idiopathic osteonecrosis of the femoral head. The purpose of this study was to determine if intravoxel incoherent motion (IVIM), a noncontrast-enhanced MRI method to simultaneously measure tissue perfusion and diffusion, can detect femoral head ischemia using a piglet model of LCPD. Twelve 6-week-old piglets underwent unilateral hip surgery to induce complete femoral head ischemia. The unoperated, contralateral femoral head served as a perfused control. The bilateral hips of the piglets were imaged in vivo at 3T MRI using IVIM and contrast-enhanced MRI 1 week after surgery. Median apparent diffusion coefficient (ADC) and IVIM parameters (diffusion coefficient: Ds; perfusion coefficient: Df; perfusion fraction: f; and perfusion flux: f*Df) were compared between regions of interest comprising the epiphyseal bone marrow of the ischemic and control femoral heads. Contrast-enhanced MRI confirmed complete femoral head ischemia in 11/12 piglets. IVIM perfusion fraction (f) and flux (f*Df) were significantly decreased in the ischemic versus control femoral heads: on average, f decreased 47 ± 27% (Δf = -0.055 ± 0.034; p = 0.0003) and f*Df decreased 50 ± 27% (Δf*Df = -0.59 ± 0.49 × 10-3 mm2/s; p = 0.0026). In contrast, IVIM diffusion coefficient (Ds) and ADC were significantly increased in the ischemic versus control femoral heads: on average, Ds increased 78 ± 21% (ΔDs = 0.60 ± 0.14 × 10-3 mm2/s; p < 0.0001) and ADC increased 60 ± 36% (ΔADC = 0.50 ± 0.23 × 10-3 mm2/s; p < 0.0001). In conclusion, IVIM is sensitive in detecting bone marrow ischemia in a piglet model of LCPD.

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.

[Clinical aspects of imaging the hip in infants, children and adolescents]. / Klinische Aspekte zur Bildgebung der kindlichen und adoleszenten Hüfte.

When a child with a hip problem is clinically evaluated, it is usually possible to make a presumptive diagnosis which is subsequently confirmed. The most important tool for confirmation in pediatric hip disorders is radiological imaging. Vice versa changes on sonogram, native X­ray or magnetic resonance images (MRI) can often only be interpreted when the history and current clinical findings are known. In this constellation, it is desirable that all colleagues who are confronted with a child's hip problem know the most common and important pediatric hip disorders and use the same terminology. The aim of this article is to present a short outline of the pathogenesis and clinical aspects of congenital and neurogenic hip dysplasia, coxitis fugax, septic coxitis, Perthes' disease, infantile and adolescent femoroacetabular impingement, apophysiolyses, and slipped capital femoral epiphysis.

[Legg-Calvé-Perthes disease]. / Morbus Perthes.

BACKGROUND: Legg-Calvé-Perthes disease (LCPD) is an important cause of limping and/or hip pain in preadolescent children. OBJECTIVE: Pathogenesis and epidemiology of LCPD, classification of disease stages, quantitative femoral head involvement and prognosis based on X­ray images and magnetic resonance imaging (MRI). MATERIAL AND METHODS: Summary and discussion of the basic research and recommendations. RESULTS: Boys between 3 and 10 years of age are mostly affected. The etiology of the femoral head ischemia is still unknown. Commonly used classifications are the stages of disease according to Waldenström and the extent of the femoral head involvement according to Catterall. Head at risk signs are used for early prognosis, and after completion of growth Stulberg's end stages are applied for long-term prognosis. CONCLUSION: Based on X­ray images and MRI, different classifications can be used for an assessment of progression and prognosis of LCPD. This systematic approach is essential to identify cases that require surgical treatment and to avoid complications such as early onset osteoarthritis of the hip.

Evaluating the effectiveness of interventions targeting only the acetabular side in the surgical treatment of Legg-Calvé-Perthes disease.

OBJECTIVE: This study aims to show the effectiveness of only acetabular-side surgeries for hips affected by Legg-Calvé-Perthes disease. PATIENTS AND METHODS: Twelve patients who underwent two different acetabular osteotomies -pembersal osteotomy and triple osteotomy - were evaluated retrospectively. Clinically, patients were examined for hip range of motion, flexion contracture, and hip extensor and abductor strength; the results were evaluated using the Harris hip score. Radiologically, the hips were assessed according to three different radiological parameters: lateral center edge angle, acetabular width, and acetabular head index at the preoperative, early postoperative, and last follow-up periods. The hips were classified according to Herring classification preoperatively and according to Stulberg classification at the last follow-up. RESULTS: Statistically significant improvement was observed in patients both clinically and radiologically. It was observed that pembersal osteotomy significantly corrected the lateral center edge angle better than triple osteotomy while also correcting the other two radiological parameters, but no statistically significant difference was observed between these methods. CONCLUSIONS: Only acetabular-side surgeries are effective and safe methods that do not require femoral intervention for hips affected by Legg-Calvé-Perthes disease and that do not show significant complications.

Outcomes of Varus Derotation Femoral Osteotomy By Angle Blade Plate in Legg-Calve-Perthes Disease for Patient Above Eight Years of Age in The Lateral Pillar B or B/C Group.

Legg-Calve-Perthes disease (LCPD) that starts after 8 years (late onset) usually follow more aggressive course and the long-term outcome is also poor. Treatment method of LCPD that will produce best results is controversial particularly if the patients are with late-onset presentation. This prospective study was conducted from January 2015 to January 2019 at Dhaka Medical College Hospital and Health N Hope Hospital, Dhaka, Bangladesh. We evaluated the radiographic outcomes for patients who had varus derotation femoral osteotomy (VDRO). We followed up 16 patients who had femoral varus osteotomy. All patients were above 8 years of age at clinical onset. The involvement of femoral epiphysis was in either in B or B/C in lateral pillar classification. All patients had MRI done to confirm radiological diagnosis and classification. The mean age was 9.5 years (range, 8 to 12 years). Final outcome was evaluated by using the Stulberg classification which was radiological. Important exclusion criteria were patient with bilateral involvement and requirement of femoral varus >30 degree. We had 81.25% of our patient with satisfactory outcomes. Among them there were Stulberg grade I, 0 cases; Stulberg grade II, 13 cases (81.25%); Stulberg III, 3 cases (18.75%), Stulberg IV and V both 0 case each. The surgical outcomes for varus derotation femoral osteotomy in late onset LCPD patients over 8 years old were showing the good results than other modalities of non surgical and surgical methods.

Reliability of the Modified Method for Sphericity Deviation Score Using Only the Involved Hip Radiographs in the Patients With Legg-Calve-Perthes Disease.

BACKGROUND: The sphericity deviation score (SDS) is a validated radiographic outcome measure that quantifies the severity of the femoral head deformity in the healed stage of Legg-Calve-Perthes disease (LCPD). The current method requires radiographs of both hips regardless of unilateral involvement to standardize radiographic magnification. As LCPD affects the unilateral hip in 85% to 90% of cases, the current method imposes unnecessary radiation exposure to most of the patients and having to exclude patients from research studies who only had unilateral hip radiographs. We thus modified the SDS method to use unilateral hip radiographs. The purpose of this study was to investigate the reliability of the modified SDS method using the radiographs containing only one hip. METHODS: This retrospective study involved 40 patients with LCPD with unilateral involvement in the healed stage of LCPD. We modified the SDS measurement method by using the distance between the teardrop and the lateral acetabulum for magnification correction and providing a clear anatomic description of reference points on the femoral head. Three independent observers performed measurements using radiographs containing the affected hip only (modified method) and both hips (conventional method). The intraclass correlation (ICC) estimates were calculated. To verify clinical relevance, the correlation of the SDS with the Stulberg classification and hip range of motion (ROM) were also investigated. RESULTS: Measurements using the modified SDS showed excellent inter-/intra-observer ICCs (0.903 to 0.978). The ICCs between the modified and conventional methods were also excellent: 0.940 to 0.966 within the same observer and 0.897 to 0.919 between different observers. The modified SDS showed moderate-to-strong correlations with the Stulberg classification (Spearman ρ=0.650) and hip ROM (Pearson r =-0.661). CONCLUSION: The modified SDS measurement method showed excellent inter-/intra-observer reliability and moderate-to-strong correlations with the Stulberg classification and hip ROM. This method will help reduce unnecessary radiation exposure in patients with unilateral LCPD and prevent the exclusion of patients with unilateral radiographs from future research studies. LEVEL OF EVIDENCE: Level III-diagnostic study.

An AI based classifier model for lateral pillar classification of Legg-Calve-Perthes.

We intended to compare the doctors with a convolutional neural network (CNN) that we had trained using our own unique method for the Lateral Pillar Classification (LPC) of Legg-Calve-Perthes Disease (LCPD). Thousands of training data sets are frequently required for artificial intelligence (AI) applications in medicine. Since we did not have enough real patient radiographs to train a CNN, we devised a novel method to obtain them. We trained the CNN model with the data we created by modifying the normal hip radiographs. No real patient radiographs were ever used during the training phase. We tested the CNN model on 81 hips with LCPD. Firstly, we detected the interobserver reliability of the whole system and then the reliability of CNN alone. Second, the consensus list was used to compare the results of 11 doctors and the CNN model. Percentage agreement and interobserver analysis revealed that CNN had good reliability (ICC = 0.868). CNN has achieved a 76.54% classification performance and outperformed 9 out of 11 doctors. The CNN, which we trained with the aforementioned method, can now provide better results than doctors. In the future, as training data evolves and improves, we anticipate that AI will perform significantly better than physicians.

Skeletal Maturity in Legg-Calve-Perthes Disease: Significant Discrepancy Present Between the Hand and the Hip.

BACKGROUND: The concept of delayed skeletal maturity in Legg-Calve-Perthes Disease (LCPD) has been well identified with the Greulich and Pyle (GP) atlas showing 1 to 2 years delay. Recently the optimized Oxford hip skeletal age (Optimized Oxford) system has been developed and shown to have similar accuracy as the GP atlas for assessing skeletal maturity. However, this system has not been used to assess skeletal maturity in LCPD. METHODS: A retrospective review of a prospective, multicenter study of patients with LCPD treated from 1984 to 1991 and followed to skeletal maturity was performed. We identified all patients who had a left-hand radiograph at the time of presentation with an accompanying anteroposterior pelvis radiograph including the contralateral hip. Patients were excluded if their age at presentation fell outside the validated range for the Optimized Oxford system. GP atlas was used to determine bone age using left-hand radiographs and the nonaffected hip radiographs were used to calculate the Optimized Oxford bone age. Skeletal maturity indices were compared with chronological age (CA) to determine the discrepancy between methodologies. RESULTS: A total of 71 patients met inclusion criteria (mean 9.5 ± 1.2 y at presentation, 42.2% females). The mean GP bone age was 1.4 years younger than CA (95% CI: 1.01-1.76 y), with the discrepancy being greater for boys than girls (1.8 vs 0.86 y, P = 0.02). The mean Optimized Oxford bone age was 0.31 years older than CA (95% CI: 0.24-0.38 y) and correlated significantly with CA ( R = 0.97, P < 0.001). There were no sex differences in the Optimized Oxford bone age relative to CA ( P = 0.32). The GP bone age was a mean of 1.7 years younger than the Optimized Oxford bone age (95% CI: 1.35-2.05 y). CONCLUSION: Skeletal maturity assessment in children with LCPD varies according to the utilized maturity system. The Optimized Oxford bone age more closely mirrors the patient's CA and does not correlate with the GP bone age, which reveals a delayed maturation.

A Comparison Between 3 Functional Hip Scores for Evaluation of the Pediatric Hip.

BACKGROUND: This investigation aimed to determine the degree of correlation among 3 functional scales for evaluating the hip in pediatric patients and determine the correlation between measures of global function and outcome. METHODS: We performed a prospective study of 173 consecutive patients (M age = 13 ± 3 y) being followed for developmental dysplasia of the hip (n = 122, 71%), slipped capital femoral epiphysis (n = 31, 18%), or Legg-Calve-Perthes disease (n = 20, 12%). We evaluated patients clinically, and we compiled scores for the Iowa Hip Score (IHS), Harris Hip Score (HHS), and Children's Hospital Oakland Hip Evaluation Scale (CHOHES). Patients concomitantly completed the Pediatric Outcomes Data Collection Instrument (PODCI) at the same clinic visit. We assessed Global Functioning Scale the and the Sports and Physical Functioning Core Scale of the PODCI. We determined the degree of correlation between the functional hip scales and between each scale and the PODCI scales using Spearman rank correlation coefficients. RESULTS: The correlations between the IHS, HHS, and CHOHES scores were robust (IHS and HHS ρ = 0.991; IHS and CHOHES ρ = 0.933; HHS and CHOHES ρ = 0.938; all P < 0.001). The correlation between the Global Functioning Scale of the PODCI and the 3 hip scores was ρ = 0.343 for the IHS, ρ = 0.341 for the HHS, and ρ = 0.352 for the CHOHES (all P < 0.001). The correlation between the sports and physical functioning core scale of the PODCI and the 3 hip scores was ρ = 0.324 for the IHS, ρ = 0.329 for the HHS, and ρ = 0.346 for the CHOHES (all P < 0.001). CONCLUSIONS: In a pediatric population with diverse hip pathology, there was a very strong correlation between scores on the IHS, HHS, and CHOHES. However, none of these 3 most commonly used hip scores correlated strongly with the global functioning scale or sports and physical functioning core scale of the PODCI. The most frequently used scores to determine the outcome of pediatric patients with hip pathology correlate strongly with each other but do not necessarily relate to global functional results. LEVEL OF EVIDENCE: Level IV.

Does Prolonged Weight Relief Increase the Chances of a Favourable Outcome After Containment for Perthes Disease?

We have been treating children with Legg-Calvé-Perthes disease (LCPD) with a femoral varus osteotomy (PFVO) and weight relief till the disease evolves to the latter part of the stage of reconstitution (Stage IIIb). This entails weight relief for 18 to 24 months. We undertook this case-control study to test if a shorter period of weight relief would compromise the chance of retaining the spherical shape of the femoral head when the disease healed. Forty-one children diagnosed in the early stages of LCPD (Stages Ia, Ib, and IIa), were treated by PFVO and non-weight-bearing for a period of 6 months following surgery (6m group). Eighty-two children with LCPD matched for age, sex, and stage at surgery, who resumed weight-bearing only once they reached Stage IIIb, served as the control group (3b group). Both groups were followed up till the disease healed. The sphericity deviation score was calculated, and the height and width of the epiphysis were measured on the first radiograph designated as Stage IV. The median sphericity deviation score value at healing was 3 in the 3b group and 11 in the 6m group (P<0.001). The frequency of spherical heads was 76% in the 3b group and 49% in the 6m group (P<0.003). The Odds Ratio of the disease healing with an aspherical head in 6-month group was 3.05 (CI: 1.28 to 7.22) compared with the 3b group. The percentage increase in width of the femoral epiphysis at healing was greater in the 6 group (111.5±8.5% vs. 106.5±7.2%; P<0.001). The study confirms that containment by PFVO performed early in the course of LCPD combined with weight relief till the disease has evolved to Stage IIIb is likely to result in spherical hips in 75% of children. Reducing the period of weight relief to 6 months may yield significantly poorer results with only 49% spherical femoral heads.

Does transepiphyseal drilling and closure of the greater trochanter in early Legg-Calve-Perthes disease improve natural history?

PURPOSE: There is no consensus regarding treatment of Legg-Calve-Perthes disease (LCPD). The most common sequel of the disease is coxa breva and overgrowth of the greater trochanter (GT). Our purpose was to examine the effectiveness of transepiphyseal drilling combined with closure of the GT apophysis in patients with LCPD. METHODS: During 2013-2018, we treated 16 consecutive cases of LCPD. Average age was 7.5 (range 6-10) years; nine patients were in early fragmentation, five in late fragmentation and one in reossification stages. Treatment protocol included hip arthrography, percutaneous drilling of the femoral head epiphysis, percutaneous tenotomy of adductor longus and epiphysiodesis of the GT apophysis. RESULTS: Mean follow-up was 38 months. One patient was lost to follow-up. All patients had a limp prior to surgery. However, at latest follow-up, 10/15 patients had no limp, 11 patients had substantial improvement in hip range of motion. On radiographs, nine patients had Stulberg type 1-2, one type 3 and five type 4-5. There was no change in the epiphysio-trochanteric distance in any patient. Eight out of nine patients treated in the early fragmentation stage had good clinical and radiographic outcome. Most patients treated in late fragmentation stage had Stulberg 4-5 hip and required additional procedures. CONCLUSIONS: Based on our preliminary experience, our protocol can be effective in the treatment of patients with LCPD in the initial or early fragmentation stages by improving the clinical and radiographic outcomes of the disease. This minimally invasive approach does not compromise any future treatment options. LEVEL OF EVIDENCE: IV.

Dega transiliac osteotomy in the treatment of advanced forms of Perthes' disease: a literature review.

The work aims to revise the current views on the effectiveness of Dega's pelvic osteotomy in preventing femoral head deformity in the course of Perthes' disease in patients with late symptoms >8 years of age and withsignificant changes in the radiographic image (Catterall III/IV or Herring B, B/C, C). We did a literature review. Four articles from six found in 'PubMed' which combine Dega acetabuloplasty and Perthes' disease words were fully read and analyzed. Kamegaya (2018), with a 9.5-year follow-up period, described differences comparing the group treated with femoral varus osteotomy with the group that was treated with a combined Dega acetabuloplasty and femoral varus osteotomy. A series of papers by Napiontek from 2004, with an average 8-year follow-up, also describes satisfactory results after Dega's osteotomy, with 27 hips in groups I/II according to Stulberg. Another paper in the series, which analyzed operatively and non-operatively treated patients, shows no differences in the period of time of Perthes disease treatment between the analyzed groups. The last paper in the series from 2001, describes 10 patients treated primarily due to hip dysplasia, who was diagnosed with Perthes disease. Five of them underwent Dega acetabuloplasty obtaining a Stulberg score of I/II in the long-term follow-up. We think it seems reasonable to return to the treatment planning of Perthes' disease using Dega acetabuloplasty as a method to improve the hip congruence in late-diagnosed and advanced forms of the disease.

Does Flexion Varus Osteotomy Improve Radiographic Findings Compared With Patients Treated in a Brace for Late-onset Legg-Calvé-Perthes Disease?

BACKGROUND: Legg-Calvé-Perthes disease (LCPD) is a childhood hip disease characterized by osteonecrosis of the femoral head. Because severe deformity of the femoral head can cause secondary osteoarthritis in adulthood, progressive collapse should be prevented in children with a necrotic epiphysis. The prognosis of patients with LCPD generally worsens as the age at disease onset increases, and the appropriate treatment for late-onset LCPD remains unclear. Based on the limited effect of nonoperative treatment using a nonweightbearing brace, flexion varus osteotomy (FVO) was introduced in 2010 as an initial treatment for late-onset LCPD in place of brace treatment, which we used in our institution before that time. QUESTIONS/PURPOSES: We asked, (1) Which treatment, FVO or a nonweightbearing brace, is associated with a lower likelihood of progressive femoral head collapse in children whose diagnosis of LCPD was made at the age of ≥ 8 years and who were followed for a minimum of 3 years after their intervention? (2) What proportion of patients in the brace group had surgery despite the treatment, and what percentage of children in the FVO group had a second operation to remove hardware and/or additional operations? METHODS: The initial treatment was applied in 181 patients with LCPD between 1995 and 2018 in our institution. Patients whose disease onset was at ≥ 8 years old (late-onset LCPD) with complete clinical and radiologic data were considered potentially eligible. In 2010, treatment for these patients changed from brace treatment to FVO for all patients. A total of 35% (42 of 121) of patients who were treated with a nonweightbearing brace between 1995 and 2009 and 40% (24 of 60) of patients who were treated with FVO between 2010 and 2018 were eligible. Among patients treated with a brace, 21% (nine of 42 patients) were excluded because of hospital transfer (three patients), short-term follow-up (three), the period from onset to the first visit was ≥ 7 months (two), and inability to use the brace because of mental incapacity (one patient). In patients treated with FVO, 12% (three of 24 patients) were excluded (two patients with a period from onset to the first visit ≥ 7 months and one with a comorbidity and multiple-epiphyseal dysplasia). Among the remaining patients, 79% (33 of 42 patients) were classified into the brace group and 88% (21 of 24 patients) were classified into the FVO group for analyses. There were no overlapping patients at the timepoint when the treatment strategy for late-onset LCPD changed. In the FVO group, subtrochanteric osteotomy with 35° to 40° of flexion and 15° to 20° of varus was performed using a locking compression plate for pediatric use. Patient demographics, radiographic parameters, and the assessment of femoral head deformity using the Stulberg classification were compared between the two groups. There was a greater proportion of boys than girls in both groups (brace: 88% and FVO: 86%), and there were no differences in the distribution of genders between the groups (p = 0.82). The right side was more frequently treated in the brace group, but there was no difference in laterality between the groups (brace: 58% right and FVO: 62% left; p = 0.16). There was no difference between groups in the median age at disease onset (9.0 years [range 8.0 to 12.5 years] in the brace group and 9.6 years [range 8.0 to 12.4 years] in the FVO group; p = 0.26). There was no difference between the groups in the period of treatment from onset (1.7 ± 1.9 months in the brace group and 1.5 ± 1.5 months in the FVO group; p = 0.73) or the follow-up period (6.7 ± 2.1 years in the brace group and 6.2 ± 2.1 years in the FVO group; p = 0.41). The LCPD stage at the first visit was assessed using the modified Waldenström classification. The intraobserver and interobserver values of the modified Waldenström classification, evaluated using kappa statistics, were excellent (kappa value 0.89 [95% CI 0.75 to 0.97]; p < 0.01) and good (kappa value 0.65 [95% CI 0.43 to 0.87]; p < 0.01). The radiographic degree of collapse at the maximum fragmentation stage was assessed using the lateral pillar classification. The intraobserver and interobserver reliabilities of the lateral pillar classification were excellent (kappa value 0.84 [95% CI 0.73 to 0.94]; p < 0.01) and excellent (kappa value 0.83 [95% CI 0.71 to 0.94]; p < 0.01). The degree of femoral head deformity at the most recent follow-up examination was compared between the groups in terms of the Stulberg classification, in which Classes I and II were classified as good and Classes III through V were classified as poor. The intraobserver and interobserver reliabilities of the Stulberg classification were good (kappa value 0.74 [95% CI 0.55 to 0.92]; p < 0.01) and good (kappa value 0.69 [95% CI 0.50 to 0.89]; p < 0.01). The evaluators were involved in the patients' clinical care as part of the treating team. RESULTS: Good radiographic results (Stulberg Class I or II) were obtained more frequently in the FVO group (76% [16 of 21 patients]) than in the brace group (36% [12 of 33 patients]), with an odds ratio of 5.6 (95% CI 1.7 to 18.5; p < 0.01). In the brace group, a subsequent femoral varus osteotomy was performed in 18% (six of 33) of patients with progressive collapse and hinge abduction, and implant removal surgery was performed approximately 1 year after the first procedure. This traditional varus osteotomy was occasionally performed in patients who were considered for conversion from nonoperative treatment before 2009 because FVO had not yet been introduced. In the FVO group, all patients (n = 21) had a second procedure to remove the implant at a mean of 10.5 ± 1.2 months postoperatively. Additional procedures were performed in 24% (five of 21) of patients, including a second FVO for progressive collapse (one patient), guided growth for a limb length discrepancy (one patient), and flexion valgus osteotomy for coxa vara in patients with a limb length discrepancy (three patients). CONCLUSION: Our historical control study found that FVO may increase the possibility of obtaining good radiographic results (Stulberg Class I or II) compared with brace treatment for patients with late-onset LCPD, although surgical interventions after the first and second implant removal procedures may be indicated. Surgeons can consider FVO if they encounter patients with late-onset LCPD, which is a challenging condition. A larger study with long-term follow-up is needed to confirm the efficacy of FVO. LEVEL OF EVIDENCE: Level III, therapeutic study.