[Legg-Calvé-Perthes disease (LCPD). Principles of diagnosis and treatment]

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.

Legg-Calvé-Perthes disease overview

Background

Legg–Calvé–Perthes Disease (LCPD) is a necrosis of the femoral head which affects the range of motion of the hips. Its incidence is variable, ranging from 0.4/100,000 to 29.0/ 100,000 children. Although LCPD was first described in the beginning of the past century, limited is known about its etiology. Our objective is to describe the main areas of interest in Legg–Calve–Perthes disease.

Methods

A review of the literature regarding LCPD etiology was performed, considering the following inclusion criteria: Studies reporting clinical or preclinical results. The research group carried out a filtered search on the PubMed and Science Direct databases. To maximize the suitability of the search results, we combined the terms ‘‘Perthes disease” OR “LCPD” OR “children avascular femoral head necrosis” with “diagnostic” OR “treatment” OR “etiology” as either key words or MeSH terms.

Results

In this article been described some areas of interest in LCPD, we include topics such as: history, incidence, pathogenesis, diagnosis, treatment and possible etiology, since LCPD has an unknown etiology.

Conclusions

This review suggests that LCPD has a multifactorial etiology where environmental, metabolic and genetic agents could be involved.

A systematic review of the non-surgical treatment of Perthes' disease

Aims

Perthes’ disease is a condition leading to necrosis of the femoral head. It is most common in children aged four to nine years, affecting around one per 1,200 children in the UK. Management typically includes non-surgical treatment options, such as physiotherapy with/without surgical intervention. However, there is significant variation in care with no consensus on the most effective treatment option.

Methods

This systematic review aims to evaluate the effectiveness of non-surgical interventions for the treatment of Perthes’ disease. Comparative studies (experimental or observational) of any non-surgical intervention compared directly with any alternative intervention (surgical, non-surgical or no intervention) were identified from: Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMcare, Allied and Complementary Medicine Database (AMED), and the Physiotherapy Evidence Database (PEDro). Data were extracted on interventions compared and methodological quality. For post-intervention primary outcome of radiological scores (Stulberg and/or Mose), event rates for poor scores were calculated with significance values. Secondary outcomes included functional measures, such as range of movement, and patient-reported outcomes such as health-related quality of life.

Results

In all, 15 studies (1,745 participants) were eligible for inclusion: eight prospective cohort studies, seven retrospective cohort studies, and no randomized controlled trials were identified. Non-surgical interventions largely focused on orthotic management (14/15 studies) and physical interventions such as muscle strengthening or stretching (5/15 studies). Most studies were of high/unknown risk of bias, and the range of patient outcomes was very limited, as was reporting of treatment protocols. Similar proportions of children achieving poor radiological outcomes were found for orthotic management and physical interventions, such as physiotherapy or weightbearing alteration, compared with surgical interventions or no intervention.

Conclusion

Evidence from non-randomized studies found no robust evidence regarding the most effective non-surgical interventions for the treatment of children with Perthes’ disease. Future research, employing randomized trial designs, and reporting a wider range of patient outcomes is urgently needed to inform clinical practice.

Cite this article: Bone Jt Open 2020;1-12:720–730.

A case review to describe variation in care following diagnosis of Perthes' disease

Aims

Perthes' disease is a condition which leads to necrosis of the femoral head. It is most commonly reported in children aged four to nine years, with recent statistics suggesting it affects around five per 100,000 children in the UK. Current treatment for the condition aims to maintain the best possible environment for the disease process to run its natural course. Management typically includes physiotherapy with or without surgical intervention. Physiotherapy intervention often will include strengthening/stretching programmes, exercise/activity advice, and, in some centres, will include intervention, such as hydrotherapy. There is significant variation in care with no consensus on which treatment option is best. The importance of work in this area has been demonstrated by the British Society for Children's Orthopaedic Surgery through the James Lind Alliance's prioritization of work to determine/identify surgical versus non-surgical management of Perthes' disease. It was identified as the fourth-highest priority for paediatric lower limb surgery research in 2018.

Methods

Five UK NHS centres, including those from the NEWS (North, East, West and South Yorkshire) orthopaedic group, contributed to this case review, with each entre providing clinical data from a minimum of five children. Information regarding both orthopaedic and physiotherapeutic management over a two-year post-diagnosis period was reviewed.

Results

Data were extracted from the clinical records of 32 children diagnosed with Perthes' disease; seven boys and 25 girls. The mean age of the children at diagnosis was 6.16 years (standard deviation (SD) 3.001). In all, 26 children were referred for physiotherapy. In the two-year period following diagnosis, children were seen a median of 7.5 times (interquartile range (IQR) 4.25 to 11) by an orthopaedic surgeon, and a median of 9.5 times (IQR 8 to 18.25) by a physiotherapist. One centre had operated on all of their children, while another had operated on none. Overall, 17 (53%) of the children were managed conservatively in the two-year follow-up period, and 15 (47%) of the children underwent surgery in the two-year follow-up period.

Conclusion

The results of this case review demonstrate a variation of care provided to children in the UK with Perthes' disease. Further national and international understanding of current care is required to underpin the rationale for different treatment options in children with Perthes' disease.Cite this article: Bone Joint Open 2020;1-11:691-695.

Assessing the role of hip arthrography in the treatment decision making for children with Legg-Calvé-Perthes disease

OBJECTIVE

The aim of this study was to determine the role of hip arthrography in the treatment decision making for children with Legg-Calvé-Perthes disease (LCPD).

METHODS

A total of 47 consecutive children with LCPD (42 boys, 5 girls; mean age=7.5 years; range=6-10 years) who underwent operative treatment were included in the study. The patient demographics, physical examination findings (pain and hip range of motion [ROM]), standard anteroposterior and Löwenstein lateral hip radiographs, and hip arthrography data were retrospectively collected. The arthrographies were performed immediately before the surgery under general anesthesia. The patients were staged according to the Catterall and Herring classifications and examined in terms of head-at-risk signs before the study. Four sets of patient files were established based on the aforementioned data, with each child in a randomized and blinded order. Ten consultant pediatric orthopedic surgeons randomly assessed the patient files on 4 separate occasions (Set 1 vs Set 2 and Set 3 vs Set 4), with a minimum time interval of 4 weeks. In the first and second sets, the demographic and clinical information, including the age, gender, hip ROM, and hip radiographs, were presented. In the third and fourth sets, hip arthrography was presented in addition to the data from Set 1 and Set 2. The observers were instructed to choose the best treatment options. The percent agreement (PA) and Gwet's AC1 statistics were used to establish a relative level of agreement among the observers.

RESULTS

The mean intra-observer reliabilities ranged from fair to moderate after adding the hip arthrography data (Gwet's AC1 = 0.36 for Set 1 vs Set 2 and 0.42 for Set 3 vs Set 4). The mean PA was 56.6% (range = 29.8% to 78.7%) with a Gwet's AC1 value of 0.51 (range: 0.21 to 0.77) between Set 1 and Set 3 (moderate intra-observer reliability). The decision for the treatment strategy was changed in 43.4% of the patients. For inter-observer reliability, Gwet's AC1 was computed as 0.48 (moderate reliability). The correlation between the intra-observer reliability and stage progression was not significant (p>0.05) for any of the subgroups. Thus, there is a negative correlation with the disease progression.

CONCLUSION

Hip arthrography seems to have a significant role in the treatment decision making for children with LCPD, especially in the advanced stages of the disease.

LEVEL OF EVIDENCE

Level IV, Therapeutic study.

The Effect of Clinical Knowledge and Surgical Experience on Treatment Choice in Legg-Calve-Perthes Disease: Intra-observer and Inter-observer Reliability Study

AIM

The aim of this study was to evaluate standardized hip radiographs, arthographs, demographic characteristics, physical examination findings, and their effects on treatment choices in leg-calve-perthes disease (LCPD). Intraobserver and interobserver realibility between orthopaedic residents, orthopaedic surgeons, and paediatric orthopaedic surgeons were also investigated.

MATERIALS AND METHODS

47 LCPD patients were included this cross-sectional study. Six separate presentations including different variabilities (clinical findings, standard radiographs, and arthrographs) were evaluated by three different groups (residents, surgeons, paediatric orthopaedic surgeons) and were sent to the observers every other month by hiding patients' personal information. Seven different treatment modalities were introduced for the best treatment modality. Intraobserver and interobserver reliability in these three groups were examined. Percentage aggreement (PA) and intraclass correlation coefficients (ICC) tests were used for this purpose.

RESULTS

Treatment PA rates between presentations were 29.5-53.6% in residents, 38.3-60.4% in surgeons, and 39.1-59.8% in pediatric orthopaedic surgeons. Conservative methods were mostly preferred as treatment modality in all groups; followed by proximal femoral osteotomies. Pediatric orthopaedic surgeons preferred safe dislocation and femur head and/or neck reconstruction surgery 5-18 times more than residents and orthopaedic surgeons. Intraobserver reliability of treatment modalities was higher among the paediatric orthopaedic surgeons; the results were fair-good (0.483-0.763). Among residents and orthopaedic surgeons, ICC values were poor to good, respectively (- 0.080 to 0.636 and 0.263-0.643). Interobserver reliability among three groups was meanly good.

CONCLUSION

As surgical experience increases, both the compliance rates of the treatment modalities and the intra- and inter-group reliability are increased. Knowledge of the demographic data and clinical findings of patients besides hip radiographs or arthrographs increase treatment compliance in paediatric orthopaedic surgeons, however, cause changes in treatment modalities in residents. As surgical experience increases, more difficult surgeries such as safe dislocation and femoral head/neck reconstruction are preferred.

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.