Aktuelle Behandlungsstrategie des Morbus Perthes

Radiographic outcome after greater trochanteric epiphysiodesis in patients with Perthes disease

Purpose

Legg-Calvé-Perthes disease often leads to greater trochanteric overgrowth, which negatively affects the biomechanics of the hip joint. This study aimed to evaluate the physiologic growth of the greater trochanter and the effectiveness of greater trochanteric epiphysiodesis radiographically.

Methods

Retrospectively, 46 children (33 male, average age at greater trochanteric epiphysiodesis 8 ± 1.3 years) with unilateral Legg-Calvé-Perthes disease undergoing greater trochanteric epiphysiodesis with screws and curettage of the epiphysis were included. On radiographs of the pelvis pre- and postoperatively (mean follow-up 3.5 years), trochanteric height, articulotrochanteric distance, and center-trochanter distance were determined and compared to the unaffected side. Reference values for the physiological development of trochanteric height, articulotrochanteric distance, and center-trochanter distance over time were established.

Results

Greater trochanteric epiphysiodesis reduced trochanteric growth by 29% measured by trochanteric height, but only statistically significant in the group "<8 years" (p = 0.02). Regression analysis revealed inhibition of trochanteric growth of 0.92 mm/year. Both articulotrochanteric distance and center-trochanter distance of the affected and unaffected side converged during the follow-up period: articulotrochanteric distance of the affected hip increased (preop: 11.2 ± 7 mm, maturity: 18.5 ± 10 mm; p < 0.01) compared to no change on the unaffected side (preop: 19.3 ± 5 mm, maturity: 18 ± 6 mm; p = 0.69). Center-trochanter distance of the affected hip stayed unchanged (preop: (-7.9) ± 7 mm, maturity: (-7.8) ± 9 mm; p = 0.13). On the unaffected side, center-trochanter distance became negative (preop: 0.9 ± 6 mm, maturity: (-6.5) ± 5 mm; p < 0.001). Measured by articulotrochanteric distance and center-trochanter distance, 31.8% achieved an optimal result.

Conclusion

Greater trochanteric epiphysiodesis has a positive effect on greater trochanter growth and therefore on hip anatomy. Further studies must show whether these positive effects also result in biomechanical and functional benefits.

Level of evidence

level III.

Predictors of radiographic outcomes of conservative and surgical treatment of Legg-Calvé-Perthes disease

PURPOSE

Treatment outcomes of conservative and surgical treatment of Legg-Calvé-Perthes disease (LCPD) have been shown to be conditioned by a number of factors that may vary across different populations. This retrospective study aimed to evaluate factors affecting radiographically assessed treatment outcomes in patients treated surgically or conservatively for LCPD at Faculty Hospital Motol, Prague, Czech Republic, between the years 2006 and 2019.

METHODS

Data of forty-seven children comprising 52 hips were analysed. Treatment outcomes were evaluated according to Stulberg classification. Predictors included the initial stage of fragmentation of the hip joint according to Herring classification, type of treatment (conservative or surgical), age at the time of diagnosis and sex.

RESULTS

Older age and severity of LCPD according to Herring classification but not the type of treatment were the strongest factors determining treatment outcomes. Treatment outcomes were comparable in patients treated conservatively or surgically both across the whole cohort of patients and a group of young children < six years of age.

CONCLUSIONS

Results strengthen the roles of severity of the LCPD at onset of treatment and age of the patient in predicting treatment outcomes in patients with LCPD. Conservative and surgical treatments appear to yield similar treatment outcomes irrespective of age of patients.

Long-term clinical and radiological outcome in patients with severe Legg-Calvé-Perthes disease after Chiari pelvic osteotomy: a mean of 14 years follow-up

INTRODUCTION

The Chiari pelvic osteotomy (CPO) has been recommended as a salvage procedure to improve head coverage in case of hip joint incongruence in paediatric hip disease. In this study, we aimed to assess the long-term results of CPO for severe Legg-Calvé-Perthes disease (LCPD).

METHODS

A total of 39 patients who underwent a CPO at our department between 1995 and 2010 were prospectively followed both radiologically (Stulberg classification) and clinically (Harris Hip Score [HHS], conversion into total hip arthroplasty). In this study, we retrospectively reviewed the cases of 12 hips (12 patients, 3 girls, 8 left hips) treated by CPO for severe LCPD (Catterall grade 3 or 4) with hip joint incongruence. Mean follow-up was 14.0 (range 7.6-21.3) years.

RESULTS

Mean age at surgery was 10.2 (range 8.2-17.8) years. Additional femoral osteotomy was performed in 8 patients. A good radiological result (Stulberg I or II) was achieved in 2 patients, a fair result (Stulberg III) in 4 patients, and a poor outcome (Stulberg IV or V) in 6 patients. Mean postoperative HHS averaged 93 (range 65-100) points. An excellent functional outcome (HHS 90-100 points) was achieved in 9 patients. No patient underwent total hip arthroplasty during follow-up. Postoperative limb-length discrepancy was found in 3 patients.

CONCLUSIONS

CPO for severe LCPD with hip joint incongruence resulted in good long-term clinical outcome in about ⅔ of our patients after a mean of 14 years. Our results suggest that CPO can still be considered as a salvage joint-conserving procedure in this selected group of younger patients.

[Juvenile osteochondrosis and osteonecrosis]

BACKGROUND

Juvenile osteonecrosis is an important topic in orthopedics. A wide variety of body regions of the growing patient are affected, predominantly during adolescence. All are characterized by a usually unknown aetiology as well as a stadium-like course. The main problem is a local osseous circulatory disorder, which causes osteonecrosis.

RISK FACTORS

Mechanical overloading due to increased body weight, axial misalignment, and sports activity is discussed as a risk factor. Healing depends on the localization and extent of the osseous necrosis.

DIAGNOSTICS

Diagnostically, radiologic imaging is used, in which the typical bony remodeling can be followed.

THERAPY

The therapeutic procedure depends on the affected region but is usually accompanied by a reduction of mechanical loading. If the clinical and radiological findings worsen, surgical treatment must be considered. The recognition and treatment of juvenile osteonecrosis is important and significantly influences the further development of the patient.

[Intertrochanteric femoral osteotomy : Indications, surgical technique, results]

BACKGROUND

Intertrochanteric osteotomies are part of joint-preserving hip surgery. Indications involve not only the mature but also the growing skeleton. After identification of the causative pathologies multidimensional corrections with the aim of a better joint situation and prevention of early osteoarthritis are possible.

METHODS

The surgical technique of intertrochanteric osteotomies is presented. Potential indications are discussed on the basis of results in the literature.

RESULTS

In the surgical treatment of developmental dysplasia of the hip intertrochanteric osteotomies are used as additional surgery. In Perthes disease the containment is improved while the onset of osteoarthritis in epiphysis capitis femoris can be decelerated. Treatment of torsion pathologies is reliable. Avascular necrosis of the femoral head and beginning osteoarthritis are critical indications.

CONCLUSION

For appropriate indications intertrochanteric osteotomies are a valuable element in joint-preserving surgery with very good long-term results.

Trichorhinophalangeal syndrome type I: a novel mutation and Perthes-like changes of the hip in a family with 4 cases over 3 generations

The trichorhinophalangeal syndrome is a rare genetic syndrome with characteristic craniofacial and skeletal abnormalities including hip pathology in variable manifestation. We describe hip involvement with Perthes-like changes and a novel mutation of the TRPSI gene in a family with 4 affected individuals. This case series underlines the clinical significance of rare genetic disorders such as TRPS that among other differential diagnoses should be kept in mind when children present with Perthes-like changes of the hip joint.

Tönnis triple pelvic osteotomy for Legg-Calve-Perthes disease

PURPOSE

The aim of this study is to evaluate the efficacy of Tönnis triple pelvic osteotomy in patients with LCP disease.

METHODS

Between 2007 and 2011, Tönnis triple pelvic osteotomy was performed for 43 patients with LCP, in our institute. During the follow-ups of patients with LCP the indications for the surgery were lateralization of the femoral head, insufficient femoral head coverage and subluxation of the femoral head. The mean age of patients at the time of surgery was 9.4 years.

RESULTS

Before surgical intervention, according to Waldenstrom classification, three patients were in the necrosis stage (7 %), six patients in the fragmentation stage (13.9 %), 16 patients in the re-ossification stage (37.2 %) and 18 patients in the remodeling stage (41.9 %). According to Herring classification, four patients were in group B (9.3 %), one patient in group B/C (2.3 %) and 38 patients in group C (88.4 %). After the operation, patients were evaluated with Stulberg classification, and good outcome (Stulberg I/II) was achieved in 23 patients (53, 5 %), fair outcome (Stulberg III) in 16 patients (37, 2 %) and poor outcome (Stulberg IV/V) was seen in only four patients (9.3 %). The mean value of CEA was 0.37° pre-operatively and in the last follow-ups the mean value of CEA was 23.7°.

CONCLUSIONS

We recommend triple pelvic osteotomy for patients with LCP when conservative methods are not successful. According to our results we believe that Waldenstrom classification is a better option than Herring classification to determine the prognosis of disease after containment surgery.

[Sleep apnea and heart failure]

Sleep apnea can influence cardiac function, by which the development of heart failure is facilitated. Vice versa, chronic heart failure increases the risk for sleep apnea. Consequently, in patients with symptomatic chronic heart failure, sleep apnea is a frequent comorbidity occuring in up to 75% of cases. More than half of those suffer from central sleep apnea, whereas in the general population, obstructive sleep apnea is far more frequent. Both, the obstructive and the central sleep apnea lead to oxygen desaturations during the night which are followed by increases in serum catecholamines. Possibly, this is the main mechanism why the prognosis of patients with symptomatic heart failure and sleep apnea is much worse than that of patients without sleep apnea. Therefore, a screening of all heart failure patients for sleep apnea is mandatory. Currently, large studies are underway which investigate whether the treatment of sleep apnea, esp. central sleep apnea, will beneficially influence the clinical course of heart failure (SERVE-HF, ADVENT-HF). A new therapeutic approach for central sleep apnea is the phrenic nerve stimulation.