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.

Treatment of Symptomatic Residual Deformity in Legg-Calvé-Perthes Disease: Mid-Term Outcomes and Predictors of Failure After Surgical Hip Dislocation with Femoral-Head Reshaping and Relative Neck Lengthening.

BACKGROUND: Treating patients with symptomatic hips after healed Legg-Calvé-Perthes disease (LCPD) is challenging, mainly because of the complexity of the deformity. We performed a retrospective study to evaluate clinical and radiographic outcomes, measure the survival rate, and identify predictors of failure following a surgical hip dislocation (SHD) with femoral-head reshaping and relative femoral-neck lengthening for the treatment of symptomatic residual hip deformity after healed LCPD. METHODS: We identified 60 patients undergoing SHD for the treatment of symptomatic residual LCPD deformity. Fifty-one (85%) of the patients (mean age, 16.3 ± 4.7 years; 21 male patients [41%]), were followed ≥4 years after surgery. We defined surgical failure as conversion to, or recommendation for, total hip arthroplasty (THA) or a Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain score of ≥10 at the most recent follow-up. We used a multivariable Cox proportional hazards model to identify factors that were predictive of failure. The rate of survival free from failure was estimated using a Kaplan-Meier curve. RESULTS: Twenty (39%) of the patients met 1 of the end-point criteria for surgical failure, while the hips of the remaining 31 (61%) of the patients were successfully preserved at a median follow-up of 10.2 years (interquartile range, 5.7 to 12.9 years). The estimated survival was 80% (95% confidence interval [CI] = 70% to 92%) at 5 years and 66% (95% CI = 53% to 81%) at 10 years. Independent factors associated with surgical failure were the severity of preoperative pain as assessed by the WOMAC pain score (hazard ratio [HR] = 1.16; 95% CI = 1.03 to 1.30; p = 0.01) and the severity of the deformity as assessed by the anteroposterior alpha angle (HR = 1.06; 95% CI = 1.01 to 1.11; p = 0.01). CONCLUSIONS: We found that SHD with relative femoral-neck lengthening and osteochondroplasty of the femoral head-neck junction was associated with improved deformity as assessed radiographically and decreased pain and symptoms of stiffness among patients with symptomatic residual LCPD deformity. Preoperative pain and deformity were identified as predictors of surgical failure. Further research is needed to establish the role of SHD and other procedures in preserving the hip over the long term. LEVEL OF EVIDENCE: Therapeutic L evel IV . See Instructions for Authors for a complete description of levels of evidence.

Radiological hip shape and patient-reported outcome measures in healed Perthes' disease.

Aims: This study aimed to evaluate the relationship between hip shape and mid-term function in Perthes' disease. It also explored whether the modified three-group Stulberg classification can offer similar prognostic information to the five-group system. Methods: A total of 136 individuals aged 12 years or older who had Perthes' disease in childhood completed the Patient-Reported Outcomes Measurement Information System (PROMIS) Mobility score (function), Nonarthritic Hip Score (NAHS) (function), EuroQol five-dimension five-level questionnaire (EQ-5D-5L) score (quality of life), and the numeric rating scale for pain (NRS). The Stulberg class of the participants' hip radiographs were evaluated by three fellowship-trained paediatric orthopaedic surgeons. Hip shape and Stulberg class were compared to PROM scores. Results: A spherical hip was associated with the highest function and quality of life, and lowest pain. Conversely, aspherical hips exhibited the lowest functional scores and highest pain. The association between worsening Stulberg class (i.e. greater deviation from sphericity) and worse outcome persisted after adjustment for age and sex in relation to PROMIS (predicted mean difference -1.77 (95% confidence interval (CI) -2.70 to -0.83)), NAHS (-5.68 (95% CI -8.45 to -2.90)), and NRS (0.61 (95% CI 0.14 to 1.08)), but not EQ-5D-5L (-0.03 (95% CI -0.72 to 0.11)). Conclusion: Patient-reported outcomes identify lower function, quality of life, and higher pain in aspherical hips. The magnitude of symptoms deteriorated with time. Hip sphericity (i.e. the modified three-group classification of spherical, oval, and aspherical) appeared to offer similar levels of detail to the five-group Stulberg classification.

Patient Adherence to Wide Abduction Brace Treatment for Legg-Calvé-Perthes Disease.

BACKGROUND: A wide abduction brace called the A-frame brace is used to contain the deformed femoral head and improve femoral head remodeling in patients with Legg-Calvé-Perthes disease (LCPD). While there is some data showing the efficacy of brace treatment, little is known about patient adherence. The purpose of this study was to measure A-frame brace adherence using temperature sensors and to identify factors that influence adherence. METHODS: This is an IRB-approved retrospective study of 61 patients with LCPD treated with an A-frame brace between ages 5 and 11. Brace wear was measured using built-in temperature sensors. Pearson correlation coefficient and multiple regression were used to determine relationships between patient characteristics and brace adherence. RESULTS: Of 61 patients, 80% were male. Mean age at LCPD onset was 5.9±1.8 years and the mean age at initiation of brace treatment was 7.1±1.5 years. Fifty-eight patients (95%) were in the fragmentation or reossification stage at the start of bracing, with 23 patients (38%) having lateral pillar B, 7 (11%) lateral pillar B/C, and 31 (51%) lateral pillar C. Forty-two (69%) patients were treated with a Petrie cast for 6 weeks before the A-frame brace. Mean adherence, defined as the ratio of measured over prescribed brace wear, was 0.69±0.32. Mean adherence improved with age ( P <0.05), increasing from 0.57 in patients less than 6 to 0.84 in patients aged 8 to 11. Patients first treated with a Petrie cast had significantly better adherence than those without (0.77 vs. 0.50; P <0.005). Adherence was negatively associated with the amount of prescribed brace wear per day ( P <0.005). Adherence did not change significantly between the start and end of treatment and was not significantly associated with sex or attention deficit hyperactivity disorder. CONCLUSIONS: A-frame brace adherence was significantly associated with age at treatment, prior Petrie casting, and the amount of daily prescribed brace wear. These findings provide new insight into A-frame brace treatment, which will lead to better patient selection and counseling to optimize adherence. LEVEL OF EVIDENCE: III Therapeutic Study.

Legg-Calve-Perthes' disease: an opportunity to prevent blindness?

Legg-Calve-Perthes' disease (LCP) is defined as avascular necrosis of the femoral head in a child and may present to a variety of disciplines from general practice to orthopaedics, paediatrics, rheumatology and more. The Stickler syndromes are a group of disorders of type II, IX and XI collagen associated with hip dysplasia, retinal detachment, deafness and cleft palate. The pathogenesis of LCP disease remains an enigma but there have been a small number of cases reporting variants in the gene encoding the α1 chain of type II collagen (COL2A1). Variants in COL2A1 are known to cause type 1 Stickler syndrome (MIM 108300, 609508), which is a connective tissue disorder with a very high risk of childhood blindness, and it is also associated with dysplastic development of the femoral head. It is unclear whether COL2A1 variants make a definitive contribution to both disorders, or whether the two are indistinguishable using current clinical diagnostic techniques. In this paper, we compare the two conditions and present a case series of 19 patients with genetically confirmed type 1 Stickler syndrome presenting with a historic diagnosis of LCP. In contrast to isolated LCP, children with type 1 Stickler syndrome have a very high risk of blindness from giant retinal tear detachment, but this is now largely preventable if a timely diagnosis is made. This paper highlights the potential for avoidable blindness in children presenting to clinicians with features suggestive of LCP disease but with underlying Stickler syndrome and proposes a simple scoring system to assist clinicians.

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.

Total hip arthroplasty through the direct anterior approach for sequelae of Legg-Calvé-Perthes disease.

INTRODUCTION: Due to multiplanar deformities of the hip, total hip arthroplasty (THA) for sequelae of Legg-Calvé-Perthes disease (LCPD) is often technically demanding. This study aimed to compare the clinical and radiographic outcomes of patients with sequelae of LCPD undergoing THA through the direct anterior approach (DAA) and non-anterior approaches to the hip. METHODS: All patients with sequelae of LCPD who underwent primary THA between 2004 and 2018 (minimum follow-up: 2 years) were evaluated and separated into two groups: THA through the DAA (Group AA), or THA through non-anterior approaches to the hip (Group non-AA). Furthermore, a consecutive control group of patients undergoing unilateral THA through the DAA for primary hip osteoarthritis (Group CC) was retrospectively reviewed for comparison. RESULTS: Group AA comprises 14 hips, group non-AA 17 hips and group CC 30 hips. Mean follow-up was 8.6 (± 5.2; 2-15), 9.0 (± 4.6; 3-17) and 8.1 (± 2.2; 5-12) years, respectively. At latest follow-up, Harris Hip Score was 90 (± 20; 26-100), 84 (± 15; 57-100), and 95 (± 9; 63-100) points, respectively. Overall, 6 patients treated for LCPD (each 3 patient in the AA and non-AA group) developed postoperative sciatic nerve palsy, of which only one was permanent. Complication-related revision rate at the latest follow-up was 15% in the AA-group and 25% in the non-AA group, respectively. CONCLUSION: THA through the DAA might be a credible option for the treatment of sequelae of LCPD with comparable complication rates and functional outcomes to non-anterior approaches.

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.

Pediatric Hip Disease Increases the Risk for Opioid Use in Adulthood: Long-term Burden of Pain and Depression.

BACKGROUND: Legg-Calvé-Perthes disease (LCPD) and slipped capital femoral epiphysis (SCFE) can result in painful deformation of the hip joint with impaired range of motion and early development of secondary osteoarthritis. It has not been investigated whether having LCPD or SCFE is associated with increased use of pain or antidepressant drug prescriptions later in life. OBJECTIVE: With this study, we aimed to investigate if patients with a history of LCPD or SCFE have an increased risk of prescription analgesic or antidepressant drugs in adulthood compared with matched controls. STUDY DESIGN: The included patients were identified by the Swedish Patient Register and matched for age, gender, and residency with 10 control individuals not exposed to any of the mentioned pediatric hip diseases, by the Swedish National Population Register. SETTING: This was a nationwide, registry-based cohort study which included 1,292 patients diagnosed with LCPD at age 2-15 years and 1,613 patients diagnosed with SCFE at age 5-16 years and > 17 years from 2005 through 2011. METHODS: Prescription data of first-line analgesic drugs (acetaminophen, nonsteroidal anti-inflammatory drugs, and opioids), or first-line antidepressant drugs (selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and tricyclic antidepressants) were derived from the Swedish Prescribed Drugs Register. Conditional logistic regression models were fitted to estimate the relative risk for the prescription in exposed compared with unexposed individuals. Adjustment was performed for gender and birth year. RESULTS: In the group with an LCPD diagnosis, the adjusted odds ratio for analgesic prescriptions overall was 1.3 (95% CI, 1.2-1.5). For patients with an SCFE diagnosis, the adjusted odds ratio for analgesic prescriptions overall was 1.4 (95% CI, 1.3-1.6). Among patients with an LCPD diagnosis, the adjusted odds ratio for antidepressant prescriptions overall was 1.0 (95% CI, 0.8-1.2). For patients with an SCFE diagnosis, the adjusted odds ratio was 1.2 (95% CI, 1.1-1.4). LIMITATIONS: As with all register studies, there are known associated biases such as selection, detection, and observational bias as well as the uncertain quality of input data. Further, the Swedish Prescribed Drugs Register only includes drugs that were prescribed by a physician and dispensed at a pharmacy. This is also a factor that may lead to underestimating the use of acetaminophen and nonsteroidal anti-inflammatory drugs, as these drugs can be acquired "over the counter." CONCLUSION: During childhood, patients with LCPD or SCFE seem to suffer long-term pain and have an increased risk of requiring analgesic medication in adulthood, including opioids. It is important to assess the causes, type, and severity of pain to optimize pain management to counteract possible overuse in these patients. Seemingly, patients with LCPD do not have an increased risk for antidepressant drug therapy in adulthood whereas we did see an increased risk for that in patients with previous SCFE compared with the general population.

Surgical hip dislocation with relative femoral neck lengthening and retinacular soft-tissue flap for sequela of Legg-Calve-Perthes disease.

OBJECTIVE: Correction of post-LCP (Legg-Calve-Perthes) morphology using surgical hip dislocation with retinacular flap and relative femoral neck lengthening for impingent correction reduces the risk of early arthritis and improves the survival of the native hip joint. INDICATIONS: Typical post-LCP deformity with external and internal hip impingement due to aspherical enlarged femoral head and shortened femoral neck with high riding trochanter major without advanced osteoarthritis (Tönnis classification ≤ 1) in the younger patient (age < 50 years). CONTRAINDICATIONS: Advanced global osteoarthritis (Tönnis classification ≥ 2). SURGICAL TECHNIQUE: By performing surgical hip dislocation, full access to the hip joint is gained which allows intra-articular corrections like cartilage and labral repair. Relative femoral neck lengthening involves osteotomy and distalization of the greater trochanter with reduction of the base of the femoral neck, while maintaining vascular perfusion of the femoral head by creation of a retinacular soft-tissue flap. POSTOPERATIVE MANAGEMENT: Immediate postoperative mobilization on a passive motion device to prevent capsular adhesions. Patients mobilized with partial weight bearing of 15 kg with the use of crutches for at least 8 weeks. RESULTS: In all, 81 hips with symptomatic deformity of the femoral head after healed LCP disease were treated with surgical hip dislocation and offset correction between 1997 and 2020. The mean age at operation was 23 years; mean follow-up was 9 years; 11 hips were converted to total hip arthroplasty and 1 patient died 1 year after the operation. The other 67 hips showed no or minor progression of arthrosis. Complications were 2 subluxations due to instability and 1 pseudarthrosis of the lesser trochanter; no hip developed avascular necrosis.

The MRI Effect in Clinical Decision Process in Perthes' Disease: "More Complex Imaging, More Complicated Surgeries".

PURPOSE OF THE STUDY Radiographs are preferred for understanding the deformity and containment in Legg-Calvé-Perthes disease (LCPD), as well as for treatment planning, but plain radiographs provide only static information and are inadequate for dynamic assessment of the joint. Magnetic resonance imaging (MRI) has been shown to be superior to other diagnostic modalities. The aim of this study was to determine the importance of hip MRI in LCPD treatment decision-making processes between pediatric orthopedic surgeons and orthopedic surgery residents. MATERIAL AND METHODS Eight orthopedic surgery residents and eight pediatric orthopedic surgeons were invited to retrospectively evaluate hip radiography images and MRI sections of 34 patients with LCPD. The treatment choices were divided into two groups as conservative and surgical. Gwet's AC1 analysis was used to establish the relative level of intra-observer agreements. The correlation between the professional experience and the agreement parameters was also evaluated using the Pearson correlation coefficient. ANOVA was used to compare multiple groups. p ≤ 0.05 was statistically significant. RESULTS For both groups most preferred treatment method was conservative approaches based on plain radiography and MRI. The resident group showed a significant shift from conservative treatment to surgical treatment choices after MRI evaluation. The difference between the frequencies of each treatment choice for pediatric orthopedic surgeons was not statistically significant among different imaging modalities, but a comparison of the changes in surgical treatment revealed a significant difference between the imaging modalities, with a trend towards more complicated treatment choices. DISCUSSION Conservative methods were the most preferred treatment choice in the study, as it is common. It was observed that treatment choices changed when patients were evaluated together with MRI. Compared to plain radiographs, MRI provides sufficient and particular information for evaluating the structures of the hip joint components. CONCLUSIONS We found that consideration of MRI data in LCPD patients changed treatment recommendations substantially towards more complicated surgical procedures. We consider this to be an 'MRI effect' where using a more complex imaging modality leads surgeons to more complicated treatment modalities in LCPD. Key words: imagnetic resonance imaging, reliability, MRI effect, Perthes disease, children.

Cooled radiofrequency ablation for pain related to Perthes' disease: a novel application.

Perthes' disease is a rare paediatric condition involving idiopathic avascular necrosis of the femoral head, leading to degenerative hip joint disease. While joint replacement surgery is considered as the definitive surgical choice of managing degenerative hip disease, alternative methods of pain relief are available, especially for young patients, to defer joint replacement to a later date. One method of reducing pain for 18-24 months is cooled radiofrequency ablation (CRFA). CRFA has been gaining recognition as an effective treatment option for chronic musculoskeletal-related pain in multiple joints. This is the first case report describing the successful use of CRFA in the non-surgical management of Perthes' disease-related osteoarthritic hip pain in a man in his 40s. CRFA treatment led to a reported subjective improvement in pain of 60%-70%, with a documented objective improvement in the Oxford Hip Score from 18 to 40 within 6 weeks of the CRFA procedure.

The modified Stulberg classification is a strong predictor of the radiological outcome 20 years after the diagnosis of Perthes' disease.

AIMS: The aim of this study was to assess the prognostic value of the modified three-group Stulberg classification, which is based on the sphericity of the femoral head, in patients with Perthes' disease. METHODS: A total of 88 patients were followed from the time of diagnosis until a mean follow-up of 21 years. Anteroposterior pelvic and frog-leg lateral radiographs were obtained at diagnosis and at follow-up of one, five, and 21 years. At the five- and 21-year follow-up, the femoral heads were classified using a modified three-group Stulberg classification (round, ovoid, or flat femoral head). Further radiological endpoints at long-term follow-up were osteoarthritis (OA) of the hip and the requirement for total hip arthroplasty (THA). RESULTS: There were 71 males (81%) and 17 females. A total of 13 patients had bilateral Perthes' disease; thus 101 hips were analyzed. At five-year follow-up, 37 hips were round, 38 ovoid, and 26 flat. At that time, 66 hips (65%) were healed and 91 (90%) were skeletally immature. At long-term follow-up, when the mean age of the patients was 28 years (24 to 34), 20 hips had an unsatisfactory outcome (seven had OA and 13 had required THA). There was a strongly significant association between the modified Stulberg classification applied atfive-year follow-up and an unsatisfactory outcome at long-term follow-up (p < 0.001). Between the five- and 21-year follow-up, 67 hips (76%) stayed in their respective modified Stulberg group, indicating a strongly significant association between the Stulberg classifications at these follow-ups (p < 0.001). CONCLUSION: The modified Stulberg classification is a strong predictor of long-term radiological outcome in patients with Perthes' disease. It can be applied at the healing stage, which is usually reached five years after the diagnosis is made and before skeletal maturity. Cite this article: Bone Joint J 2021;103-B(12):1815-1820.

Leg length discrepancy in patients with Perthes' disease : a note of caution for the arthroplasty surgeon.

AIMS: Perthes' disease (PD) often results in femoral head deformity and leg length discrepancy (LLD). Our objective was to analyze femoral morphology in PD patients at skeletal maturity to assess where the LLD originates, and evaluate the effect of contralateral epiphysiodesis for length equalization on proximal and subtrochanteric femoral lengths. METHODS: All patients treated for PD in our institution between January 2013 and June 2020 were reviewed retrospectively. Patients with unilateral PD, LLD of ≥ 5 mm, and long-leg standing radiographs at skeletal maturity were included. Total leg length, femoral and tibial length, articulotrochanteric distance (ATD), and subtrochanteric femoral length were compared between PD side and the unaffected side. Furthermore, we compared leg length measurements between patients who did and who did not have a contralateral epiphysiodesis. RESULTS: Overall, 79 patients were included, of whom 21 underwent contralateral epiphysiodesis for leg length correction. In the complete cohort, the mean LLD was 1.8 cm (95% confidence interval (CI) 1.5 to 2.0), mean ATD difference was 1.8 cm (95% CI -2.1 to -1.9), and mean subtrochanteric difference was -0.2 cm (95% CI -0.4 to 0.1). In the epiphysiodesis group, the mean LLD before epiphysiodesis was 2.7 cm (95% CI 1.3 to 3.4) and 1.3 cm (95% CI -0.5 to 3.8) at skeletal maturity. In the nonepiphysiodesis group the mean LLD was 2.0 cm (95% CI 0.5 to 5.1; p = 0.016). The subtrochanteric region on the PD side was significantly longer at skeletal maturity in the epiphysiodesis group compared to the nonepiphysiodesis group (-1.0 cm (95% CI -2.4 to 0.6) vs 0.1 cm (95% CI -1.0 to 2.1); p < 0.001). CONCLUSION: This study demonstrates that LLD after PD originates from the proximal segment only. In patients who had contralateral epiphysiodesis to balance leg length, this is achieved by creating a difference in subtrochanteric length. Arthroplasty surgeons need to be aware that shortening of the proximal femur segment in PD patients may be misleading, as the ipsilateral subtrochanteric length in these patients can be longer. Therefore, we strongly advise long-leg standing films for THA planning in PD patients in order to avoid inadvertently lengthening the limb. Cite this article: Bone Joint J 2021;103-B(11):1736-1741.

Hip Morphology in Early-stage LCPD: Is There an Argument for Anatomic-specific Containment?

BACKGROUND: Early containment surgery has become increasingly popular in Legg-Calvé-Perthes Disease (LCPD), especially for older children. These procedures treat the proximal femur, the acetabulum, or both, and most surgeons endorse the same surgical option regardless of an individual patient's anatomy. This "one-surgery-fits-all" approach fails to consider potential variations in baseline anatomy that may make one option more sensible than another. We sought to describe hip morphology in a large series of children with newly diagnosed LCPD, hypothesizing that variation in anatomy may support the concept of anatomic-specific containment. METHODS: A retrospective review of a prospectively collected multicenter database was conducted for patients aged 6 to 11 at diagnosis. To assess anatomy before significant morphologic changes secondary to the disease itself, only patients in Waldenström stages IA/IB were included. Standard hip radiographic measurements including acetabular index, lateral center-edge angle, proximal femoral neck-shaft angle (NSA), articulotrochanteric quartiles, and extrusion index (EI) were made on printed anteroposterior pelvis radiographs. Age-specific percentiles were calculated for these measures using published norms. Significant outliers (≤10th/≥90th percentile) were reported where applicable. RESULTS: A total of 168 patients with mean age at diagnosis of 8.0±1.3 years met inclusion criteria (81.5% male). Mean acetabular index for the entire cohort was 16.8±4.1 degrees; 58 hips (34.5%) were significantly dysplastic compared with normative data. Mean lateral center-edge angle was 15.9±5.2 degrees at diagnosis; 110 (65.5%) were ≤10th percentile indicating dysplasia (by this metric). Mean NSA overall was 136.5±7.0 degrees. Fifty-one (30.4%) and 20 (11.9%) hips were significantly varus (≤10th percentile) or valgus (≥90th percentile), respectively. Thirty-five hips (20.8%) were the third articulo-trochanteric quartiles or higher suggesting a higher-riding trochanter at baseline. Mean EI was 15.5%±9.0%, while 63 patients (37.5%) had an EI ≥20%. CONCLUSIONS: The present study finds significant variation in baseline anatomy in children with early-stage LCPD, including a high prevalence of coexisting acetabular dysplasia as well as high/low NSAs. These variations suggest that the "one-surgery-fits-all" approach may lack specificity for a particular patient; a potentially wiser option may be an anatomic-specific containment operation (eg, acetabular-sided osteotomy for coexisting dysplasia, varus femoral osteotomy for valgus NSA). LEVEL OF EVIDENCE: Level IV.

Relationship of peroxidation indicators and hemograms in children with hip joint pathology.

The increase in the number of patients with hip pathologies among children of different ages makes the diagnosis and treatment of these diseases one of the most actually existing problems in modern orthopedics. The aim of the work was to determine the features of the lipid peroxidation system - antioxidant protection and hemogram indices in children with various forms of hip joint pathology. The results of a preoperative examination of 47 patients aged 6-15 years (average age 10.3 years) who were treated at the clinic "FSBI NICC" TO "named after academician G. A. Ilizarova, Ministry of Health of the Russian Federation. There were 25 boys and 20 girls. Given nosology, patients were divided into five groups. The diagnosis was established on the basis of a clinical and radiological examination. Group I consisted of 8 male patients with stage II Perthes disease (mean age 8.75 + 1.63). Group II includes 16 patients (8 boys, 7 girls) with stage III Perthes disease. (average age 11.80 + 0.89). Group III included 12 patients (6 boys, 6 girls) with aseptic necrosis of the femoral head (average age 14.7 + 2.35). Group IV consisted of 4 patients (1 boy, 3 girls) with epiphyseal dysplasia. (average age 10.25 + 1.36). Group V includes 7 patients with hip dysplasia complicated by aseptic necrosis of the femoral head (mean age 8.33 + 2.11). The norm is the data that was obtained after examining 10 healthy male adolescents (age 13-14) and 5 female adolescents (age 8-14 years). Changes in lipid peroxidation rates and antioxidant activity are unidirectional in different forms of pathology of the hip joints in children, and the content of peroxidation products reliably correlates with hemogram values in stage II osteochondropathy and complicated hip dysplasia. In the complex of diagnostic measures for children with dystrophic lesions of the hip joint, to clarify the nature and stage of the pathological process, as additional criteria, hemogram indicators and lipid peroxidation systems - antioxidant protection can be used.

Hip Injuries in the Adolescent Athlete.

This article provides concise and up-to-date information on the most common hip pathologies that affect adolescent athletes. We cover the evaluation and treatment of avulsion injuries, stress fractures, slipped capital femoral epiphysis (SCFE), femoroacetabular impingement, developmental dysplasia of the hip, Legg-Calve-Perthes disease, and coxa saltans focusing on minimizing advanced imaging and using conservative therapy when applicable. Although this is not an all-encompassing list of disorders, it is key to understand these hip pathologies because these injuries occur commonly and can also have detrimental complications if not diagnosed and addressed early, especially SCFE and femoral neck stress fractures.

Medium-term outcomes of total hip arthroplasty in juvenile patients.

BACKGROUND: Juvenile hip osteoarthritis is often the end result of congenital conditions or acquired hip ailments occurred during the paediatric age. This study evaluated the middle term results of total hip arthroplasty for end-stage juvenile hip osteoarthritis. MATERIALS AND METHODS: This is a retrospective analysis of prospectively collected data on a cohort of 10 consecutive patients (12 hips), aged between 14 and 20 at operation, who underwent cementless total hip arthroplasty for end-stage juvenile secondary hip osteoarthritis in two orthopaedic tertiary referral centres between 2009 and 2018. RESULTS: Juvenile hip osteoarthritis occurred as a consequence of developmental dysplasia of the hip, Legg-Calvé-Perthes disease, femoral head necrosis or slipped capital femoral epiphysis. All patients showed a significant improvement in Harris Hip Score (p < 0.01) at 3.3 years average follow-up (range 0.7-10.1 years). CONCLUSION: The management of juvenile hip osteoarthritis following developmental dysplasia of the hip, Legg-Calvé-Perthes disease, femoral head necrosis or slipped capital femoral epiphysis is still challenging. Careful preoperative planning is essential to achieve good outcomes and improve the Harris Hip Score in these young patients. Total hip arthroplasty is a suitable option for end-stage secondary juvenile hip osteoarthritis, when proximal femoral osteotomies and conservative treatments fail to improve patients' symptoms and quality of life. LEVEL OF EVIDENCE: IV.

Impingement-free hip range of motion after osteochondroplasty and relative neck lengthening in adults with healed Perthes disease.

OBJECTIVE: Our main objective is to assess the efficiency of the osteochondroplasty with relative neck lengthening in adults with healed Perthes clinically (through assessment of impingement-free hip ROM, functional scores) and radiographically. PATIENTS AND METHODS: This was a prospective case series study included 30 hips of 30 patients who underwent osteochondroplasty and RNL due to symptomatic healed LCPD. This study included 16 males (53.3%) and 14 females (46.7%). The age of patients ranged from 19 to 40 years with mean age 26.4 years at the date of surgery (SD 6.4). RESULTS: Median time of follow-up was 27.7 months after surgery (range 12-60 months). Two patients (6.6%) developed avascular necrosis (AVN) and needing total hip replacement; none of our patients developed nerve injury, detachment of the trochanteric fragment, and wound infection needing treatment. Preoperative Stulberg classes II and III improved more than preoperative Stulberg classes IV and V, although not statistically significant (P = 0.1104, n = 30). The mean HHS and WOMAC score values for each patient were higher in the Stulberg II and III groups compared to the Stulberg IV and V groups CONCLUSION: Head and neck osteochondroplasty performed through the surgical dislocation approach, combined with RFNL, relieved pain and restored function in most of the patients with reasonable complications. LEVEL OF EVIDENCE: IV.