Percutaneous innominate pelvic osteotomy without the use of bone graft for femoral head coverage in children 2-8 years of age

Epidemiology, natural evolution, pathogenesis, clinical spectrum, and management of Legg-Calvé-Perthes

Background

Legg-Calvé-Perthes disease is a self-limiting disorder that develops in children following interruption of the blood supply to the capital femoral epiphysis. This review outlines the current knowledge on the epidemiology, natural evolution, clinical spectrum, and management of the disease.

Methods

The literature pertaining to these aspects of the disease were studied and summarized in this review.

Results

Epidemiological studies suggest that environmental factors contribute to the causation of the disease. Incidence rates monitored over time indicate that the incidence of Legg-Calvé-Perthes disease is declining. The natural evolution followed on sequential plain radiographs enables division of the disease into Stages Ia, Ib, IIa, IIb, IIIa, IIIb, and IV. Reversible deformation of the capital occurs in Stages Ia-IIa simply on standing while irreversible deformation may occur in Stages IIb and IIIa. Treatment of Legg-Calvé-Perthes disease in Stages Ia-IIa aims to prevent the femoral head from getting deformed by containment and avoidance of weight-bearing. In Stages IIb and IIIa, treatment aims to remedy the effects of early irreversible deformation of the femoral head. In Stage IIIb and IV, treatment is directed to correcting the altered shape of the femoral head. The impression that these treatment methods are helpful is based on poor quality evidence.

Conclusion

There is an urgent need to undertake Level I studies to establish the efficacy of currently treatment.

Level of evidence

level V.

Proposal of a New Type of Innominate Osteotomy without the Use of Bone Graft in Children: A Preliminary Study

Good long-term outcomes have been reported for the Salter innominate osteotomy (SIO), which is widely used to correct developmental dysplasia of the hip (DDH) in children. In this study, we describe the procedure and early outcomes of a new pelvic osteotomy termed "angulated innominate osteotomy" (AIO).

METHODS

Twenty-one patients (22 hips) underwent AIO. We evaluated age at the time of surgery, operative time, blood loss, and time to bone union. Several radiographic parameters were assessed preoperatively, immediately postoperatively, and at the time of the latest examination. Measurements were compared with those of 20 previous patients who underwent SIO. The AIO is made to form an isosceles triangle. This enables 2 points of contact between the proximal and distal bone fragments, eliminating the need for a bone graft.

RESULTS

Mean age at the time of surgery was 5.9 years, and the mean duration of follow-up was 30.8 months. The mean operative time was 103 minutes, mean blood loss was 33 mL, and mean time to bone union was 9.8 weeks. Immediately postoperatively, the mean "distance d" (lateral displacement of the distal fragment), mean ratio of the obturator heights (ROH), and mean lateral rotation angle (LRA) were 7.2 mm, 70.4%, and 19.3°, respectively. At the latest examination, the mean acetabular index (AI), center-edge angle (CEA), and acetabular head index (AHI) were 16.4°, 23.7°, and 85.5%, respectively, each of which were significantly improved compared with the preoperative values. Moreover, the mean postoperative iliac length difference (ILD) between the operative and contralateral sides was only 0.1 mm. Those treated with AIO had a significantly shorter operative time and time to bone union, and less blood loss, than those treated with SIO. The mean distance d, ROH, and LRA did not differ significantly from SIO results, while the mean ILD was significantly less.

CONCLUSIONS

AIO is a less-invasive procedure that does not require a bone graft, and the short-term outcomes were favorable. Sufficient coverage of the acetabulum with displacement of the distal bone fragment to an extent similar to SIO can be achieved; we consider AIO a worthy surgical procedure that has the potential to provide good long-term outcomes similar to those seen with SIO.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Minimally invasive, iliac crest-sparing approach for pelvic osteotomies in children

The aim of this article is to describe a minimally invasive iliac crest-sparing approach (ICSA) allowing common iliac osteotomies in children. The ICSA was used for 98 hips in 72 consecutive patients who underwent a pelvic osteotomy. The mean follow-up duration ranged from 3 to 7 years. Skin incision ranged from 3 to 5.5 cm. Displacement of the distal osteotomy fragment was easy and without tension. The duration of surgery varied from 50 min in the beginning of our experience to 20-25 min for the last cases of the series. In conclusion, the ICSA fulfills all the criteria of minimally invasive surgery.

Management and treatment of osteonecrosis in children and adolescents with acute lymphoblastic leukemia

There is no consensus regarding how to manage osteonecrosis in pediatric acute lymphoblastic leukemia patients. Therefore, we performed a quality assessment of the literature with the result of a search strategy using the MESH terms osteonecrosis, children, childhood cancer, surgery, bisphosphonates, 6 hydroxymethyl-glutaryl CoA reductase inhibitors, anticoagulants and hyperbaric oxygen, and terms related to these MESH terms. A randomized controlled trial showed that osteonecrosis can be prevented by intermittent, instead of continuous, corticosteroid administration. The studies on interventions after onset of osteonecrosis were of low-quality evidence. Seven pediatric acute lymphoblastic leukemia studies described non-surgical interventions; bisphosphonates (n=5), hyperbaric oxygen therapy (n=1), or prostacyclin analogs (n=1). Safety and efficacy studies are lacking. Five studies focused on surgical interventions; none was of sufficient quality to draw definite conclusions. In conclusion, preventing osteonecrosis is feasible in a proportion of the pediatric acute lymphoblastic leukemia patients by discontinuous, instead of continuous, steroid scheduling. The questions as to how to treat childhood acute lymphoblastic leukemia patients with osteonecrosis cannot be answered as good-quality studies are lacking.

Modified triple innominate osteotomy for acetabular dysplasia: for better femoral head medialization and coverage

Steel's triple innominate osteotomy was created for correcting dysplastic acetabulum in adolescents and young adults. We modified Steel's triple innominate osteotomy with two anterior incisions and ramus cuts close to the acetabulum to improve the mobility of the fragment for better coverage of the hip. The purpose of this study was to compare these two techniques with respect to acetabular morphology, femoral head coverage, and medialization. From 1989 to 2007, 22 hips from 19 adolescents and young adults underwent triple innominate osteotomy for symptomatic acetabular dysplasia with Tonnis grades 1 or 2. We divided patients into group A (11 hips from 10 patients), comprising patients who underwent classical Steel's osteotomy, and group B (11 hips from nine patients), comprising patients who underwent modified Steel's osteotomy, with a minimum follow-up of 2 years. Preoperative and postoperative radiographs of pelvis in the standing position were available for comparison. We used Sharp's angle, center-edge angle, femoral head extrusion index, and center-head distance discrepancy to evaluate hip morphology, femoral head coverage, and medialization, respectively. The paired t-test was used for statistical calculation with P-value less than 0.05 considered significant. The postoperative Sharp's angle, center-edge angle, femoral head extrusion index, and center-head distance discrepancy all had better results in group B with statistical significance. Other variants such as age, sex, and operation side did not have any significance. No postoperative complication was encountered. Our modified technique provided a better mobility of the rotated fragment in correcting acetabular dysplasia with a short learning curve. Most importantly, we provided greater coverage and medialization of the femoral head for better long-term results.

LEVEL OF EVIDENCE

level III, retrospective comparative study.