1
|
Massè A, Giachino M, Audisio A, Donis A, Giai Via R, Secco DC, Limone B, Turchetto L, Aprato A. Ganz femoral head reduction associated with coverage and containment procedures improve radiological and functional outcomes in Perthes' disease. Bone Joint J 2024; 106-B:40-46. [PMID: 38688483 DOI: 10.1302/0301-620x.106b5.bjj-2023-0853.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
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.
Collapse
Affiliation(s)
- Alessandro Massè
- Ortopedia e Traumatologia 1U, Centro Traumatologico Ortopedico, Città della Salute e della Scienza, Torino, Italy
- Dipartimento di Scienze Chirurgiche, Università degli Studi di Torino, Torino, Italy
| | - Matteo Giachino
- Ortopedia e Traumatologia 1U, Centro Traumatologico Ortopedico, Città della Salute e della Scienza, Torino, Italy
| | - Andrea Audisio
- Ortopedia e Traumatologia Pediatrica, Ospedale Infantile Regina Margherita, Torino, Italy
| | - Andrea Donis
- Dipartimento di Scienze Chirurgiche, Università degli Studi di Torino, Torino, Italy
| | - Riccardo Giai Via
- Dipartimento di Scienze Chirurgiche, Università degli Studi di Torino, Torino, Italy
| | - Davide C Secco
- Dipartimento di Scienze Chirurgiche, Università degli Studi di Torino, Torino, Italy
| | - Beatrice Limone
- Dipartimento di Scienze Chirurgiche, Università degli Studi di Torino, Torino, Italy
| | - Luigino Turchetto
- UOC Ortopedia e Traumatologia, Ospedale di Portogruaro, Portogruaro, Italy
| | - Alessandro Aprato
- Ortopedia e Traumatologia 1U, Centro Traumatologico Ortopedico, Città della Salute e della Scienza, Torino, Italy
- Dipartimento di Scienze Chirurgiche, Università degli Studi di Torino, Torino, Italy
- Ortopedia e Traumatologia Pediatrica, Ospedale Infantile Regina Margherita, Torino, Italy
| |
Collapse
|
2
|
Lal JV, Tontanahal S, Francis J, Philip KM, Lj R, Kurian BT. Functional Outcome of Varus Derotation Osteotomy in Legg-Calve-Perthes Disease: Can It Be Justified in Late-Presenting Disease? Cureus 2023; 15:e49788. [PMID: 38161572 PMCID: PMC10757815 DOI: 10.7759/cureus.49788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND Legg-Calve-Perthes disease (LCPD) in children older than seven years has often been associated with accelerated progress and poor outcome. The results of varus derotation osteotomy (VDRO) of the proximal femur in this cohort are not consistently predictable. This study was aimed at assessing the functional outcome of VDRO for hip containment in children with late-presenting LCPD. MATERIALS AND METHODS A quasi-prospective observational study was conducted to determine the functional outcomes of children with late-presenting unilateral LCPD who underwent VDRO between 2016 and 2021, with a minimum follow-up of two years. A retrospective chart review followed by a patient/parent-reported outcome measure using the Paediatric Outcome Data Collection Instrument (PODCI) was utilised. RESULTS Thirteen children were included in this study, with a mean age of 8.30 years (range: 7-12 years; SD: -1.493). Three children were in the early stages of the disease, modified Elizabethtown I and IIA (1 and 2, respectively). The majority of the children were in Stage IIB of the modified Elizabethtown staging (n=6), followed by Stage IIIA (n=4). The two children presenting in Stage IV of the disease were excluded from the analysis. The mean standardised and normative PODCI scores for transfer and mobility were 98.23 and 48.03, respectively. The mean standardised and normative PODCI scores for sports and physical were 93.15 and 49.76, respectively. Neither of the scores showed a statistically significant difference between the late and early stages of the disease (Transfer and Basic Mobility Scale: Standardised (p=0.273), Normative (p=0.268); Sports and Physical Functioning Scale: Standardised (p=0.618), Normative (p=0.631)). However, a higher mean PODCI score was noted for the early stages. There was no statistically significant difference between the median score and the duration since surgery. However, there was a moderate negative correlation between the time scores and the times since surgery for the late stages of the disease, viz. Stage IIB and IIIA (Transfer and Basic Mobility Scale: Standardised (-0.445), Normative (-0.450); Sports and Physical Functioning Scale: Standardised (-0.228), Normative (-0.228)). This correlation, however, did not reach a statistical significance. CONCLUSION VDRO can be regarded as a functionally rewarding option for femoral head containment in late-presenting LCPD across the evolutionary stages of the disease.
Collapse
Affiliation(s)
- Jaya V Lal
- Orthopaedics, St. John's Medical College Hospital, Bangalore, IND
| | - Sagar Tontanahal
- Orthopaedics, St. John's Medical College Hospital, Bangalore, IND
| | - Joseph Francis
- Orthopaedics, St. John's Medical College Hospital, Bangalore, IND
| | - Kevin M Philip
- Orthopaedics, St. John's Medical College Hospital, Bangalore, IND
| | - Ramesh Lj
- Orthopaedics, Dr. Chandramma Dayananda Sagar Institute of Medical Education and Research, Bangalore, IND
| | - Binu T Kurian
- Orthopaedics, St. John's Medical College Hospital, Bangalore, IND
| |
Collapse
|
3
|
Mushtaq N, Osmani H, Patel J, Alwan S, Sarraf K, Ahmed N. Evaluation of paediatric hip pain. Br J Hosp Med (Lond) 2023; 84:1-10. [PMID: 37490445 DOI: 10.12968/hmed.2023.0054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
Hip pain in a child can pose a diagnostic conundrum. In most cases, the cause of a painful hip is often attributed to trauma, but a number of these cases will be atraumatic. The main entities to consider are inflammatory, infective and neoplastic causes. Pathologies such as avascular necrosis and slipped upper femoral epiphysis can also present in a similar manner. A detailed history and clinical examination are crucial in narrowing down the differential diagnosis. In addition, understanding the most appropriate imaging modalities and the characteristic radiological findings is key in ensuring timely treatment and management. This article reviews the various disease processes in children who present with hip pain and outlines the most appropriate assessment and imaging modalities that will aid diagnosis.
Collapse
Affiliation(s)
- Nida Mushtaq
- Department of Imaging, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Humza Osmani
- Department of Trauma and Orthopaedics, Addenbrooke's Hospital, Cambridge, UK
| | - Jugal Patel
- Department of Imaging, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Samir Alwan
- Department of Imaging, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Khaled Sarraf
- Department of Trauma and Orthopaedics, St Mary's Hospital, Imperial College Healthcare Trust, London, UK
| | - Naeem Ahmed
- Department of Imaging, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| |
Collapse
|
4
|
LaGreca J, Nickel A, Finch M, Martin BD, Laine JC. Declining Rates of Legg-Calvé-Perthes Surgery in the United States: National Trends Using the Kids' Inpatient Database and Pediatric Health Information System. J Pediatr Orthop 2023; 43:343-349. [PMID: 36952260 DOI: 10.1097/bpo.0000000000002388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
BACKGROUND In 2004 and 2008 two large prospective, multicenter studies were published which resulted in improved understanding of operative indications for the treatment of Legg-Calvé-Perthes disease (LCPD) based on patient age, disease severity, and resultant radiographic outcomes. The primary aim of this study is to evaluate the trends in surgical management of LCPD in the United States prior, and subsequent to, the publication of these landmark studies. METHODS Cross-sectional retrospective analysis of US pediatric hospitalizations for the surgical management of LCPD was conducted using the Kids' Inpatient Database from 2000 to 2016. Patients 12 years of age and younger were included who had a primary admission diagnosis of LCPD and a LCPD-related procedure during the hospitalization. Data was subsequently weighted to produce national-level estimates and variables pertaining to patient age group, procedure, demographics, and hospital characteristics were analyzed. In a post hoc analysis, the results of the Kids' Inpatient Database were also corroborated with the Pediatric Health Information System database. RESULTS A weighted sample of 2786 LCPD surgical admissions met inclusion and exclusion criteria; 11.2% of surgical admissions were patients below 6 years of age, 35.9% were 6 to 8 years of age, and 52.9% were above 8 years of age. There was a significant decrease in admissions for surgical management of LCPD in all age groups over time, however there was no appreciable change in the proportion of LCPD surgical admissions performed among the above 8 to below 12, above 6 to below 8, or below 6 years age groups. Femoral osteotomy remained the most common surgical procedure, while other osteotomy types, including pelvic and unspecified osteotomies involving the hip, decreased over time ( P <0.001). CONCLUSIONS There is a decreasing rate of hospital admissions for LCPD surgery since 2000, perhaps indicating a decline in incidence of disease. Furthermore, despite evidence supporting LCPD surgical outcomes related to patient age, there has been no change in the proportion of patients undergoing surgery by age group over time. LEVEL OF EVIDENCE Level III-retrospective study.
Collapse
Affiliation(s)
- Jaren LaGreca
- Gillette Children's Specialty Healthcare, Saint Paul
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis
| | | | | | | | - Jennifer C Laine
- Gillette Children's Specialty Healthcare, Saint Paul
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis
| |
Collapse
|
5
|
Grace F, Ashby E. Late Presentation of Tricho-Rhino-Phalangeal Syndrome (TRPS1 Affected) Associated Hip Pathology. J Med Cases 2023; 14:244-250. [PMID: 37560551 PMCID: PMC10409537 DOI: 10.14740/jmc4125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Indexed: 08/11/2023] Open
Abstract
Perthes disease typically presents between the ages of 4 and 9 years and is characterized by unilateral or bilateral avascular necrosis of the femoral head. Clinically it presents with pain and decreased range of motion and has a disease course of up to 5 years. We report the clinical and radiological findings of a female in early adolescence who was referred to pediatric physiotherapy and found to have Perthes-like changes of the hip, on a background of tricho-rhino-phalangeal syndrome type 1 (TRPS1). The patient's first symptoms of hip pain were reported at age 10, but there was no radiographic evidence until 2.5 years later when a diagnosis of Perthe's disease was made. This uniquely late presentation may have been due to the altered skeletal maturation seen in TRPS1, whereby skeletal age lags behind chronological age. This case highlights the importance of identifying relevant past medical history on initial assessment, and having rapid access to radiology and orthopedic support to enable timely diagnosis, as prognosis becomes poorer as age increases. Perthes-like changes should be considered as a differential diagnosis in patients presenting with non-traumatic hip pain, regardless of age of onset.
Collapse
Affiliation(s)
- Faye Grace
- Physiotherapy Department, Cambridge University Hospital NHS Foundation Trust, Cambridge, CB2 OQQ, UK
| | - Elizabeth Ashby
- Department of Paediatric Orthopaedics, Cambridge University Hospital NHS Foundation Trust, Cambridge, CB2 OQQ, UK
| |
Collapse
|
6
|
Xiao YB, Du W, Wu PF, Qing LM, Yu F, Tang JY. Pedicled iliac bone flap grafting in the treatment of late presentation Legg–Calvé–Perthes disease. Front Surg 2023; 10:926109. [PMID: 37066005 PMCID: PMC10090281 DOI: 10.3389/fsurg.2023.926109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 03/10/2023] [Indexed: 03/30/2023] Open
Abstract
BackgroundLegg–Calvé–Perthes disease (LCPD) is a juvenile form of ischemic femoral head osteonecrosis affecting children. The lack of effective and timely treatment results in severe sequelae in children (especially older ones). Although LCPD has been widely studied, little is known about its etiology. As a result, its clinical management is still challenging. This study will investigate the clinical and radiological results of patients older than 6 years and treated with pedicled iliac bone flap grafting for LCPD.Materials and methodsA total of 13 patients (13 hips) with late presentation of LCPD were treated with pedicled iliac bone flap grafting. Of the 13 patients, 11 were male and 2 were female. The average age of the patients was 8.4 years (range 6–13). Preoperational radiographs and pain scores were analyzed for lateral pillar classification and the Oucher scale. The final follow-up radiograph was classified using a modified Stulberg classification. Limping, extremity length inequality, and range of motion were clinically assessed.ResultsThe average follow-up of the patients was 70 months (range 46–120). During the surgery, seven hips were found to be lateral pillar grade B, two were grade B/C, and four were grade C. In the final examination, 12 hips were evaluated as good (Stulberg class I or II) and one as medium (Stulberg class III). There was limb shortening in one patient who was Stulberg class III. There was a significant difference between the preoperational and postoperational radiographic values and the Ocher scale, regardless of the surgical staging (P < 0.05).ConclusionsPedicled iliac bone flap graft can treat LCPD accompanied by pain and lateral pillar stage B, B/C, and C in children over 6 years.Level of EvidenceLevel IV—case series.
Collapse
Affiliation(s)
- Yong-bing Xiao
- Department of Orthopedics, Xiangya Hospital, Central South University, Changsha, China
| | - Wei Du
- Department of Orthopedics, Xiangya Hospital, Central South University, Changsha, China
- Department of Rehabilitation Medicine, Xiangya Hospital, Central South University, Changsha, China
| | - Pan-feng Wu
- Department of Orthopedics, Xiangya Hospital, Central South University, Changsha, China
| | - Li-ming Qing
- Department of Orthopedics, Xiangya Hospital, Central South University, Changsha, China
| | - Fang Yu
- Department of Orthopedics, Xiangya Hospital, Central South University, Changsha, China
| | - Ju-Yu Tang
- Department of Orthopedics, Xiangya Hospital, Central South University, Changsha, China
- Correspondence: Ju-Yu Tang
| |
Collapse
|
7
|
Caldaci A, Testa G, Dell’Agli E, Sapienza M, Vescio A, Lucenti L, Pavone V. Mid–Long-Term Outcomes of Surgical Treatment of Legg-Calvè-Perthes Disease: A Systematic Review. CHILDREN 2022; 9:children9081121. [PMID: 36010012 PMCID: PMC9406809 DOI: 10.3390/children9081121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 07/18/2022] [Accepted: 07/22/2022] [Indexed: 11/23/2022]
Abstract
Background: Legg–Calvè–Perthes disease (LCPD) is a common childhood disease that usually occurs in 4- to 12-year-old children. Surgical treatment consists of femoral, pelvic, or combined osteotomies. This comprehensive review aimed to investigate the mid- and long-term outcome of the surgical treatment. Methods: A systematic review of PubMed, Science Direct, and MEDLINE databases was performed by two independent authors, using the keywords “outcome”, “surgical treatment”, “pelvic osteotomy”, “femoral osteotomy”, and “Legg–Calvè–Perthes disease” to evaluate studies of any level of evidence that reported the surgical outcome of LCPD. The result of every stage was reviewed and approved by two senior investigators. Results: A total of 2153 articles were found. At the end of the screening, we selected 23 articles eligible for full-text reading according to the inclusion and exclusion criteria. Our analysis showed that the main prognostic factors for surgical outcome in patients with LCPD are the age at onset and the degree of initial disease severity. Conclusions: Surgical treatment in patients older than 6 years has excellent results in Herring B and B/C hips and poor results in Herring C hips, with a slight advantage for patients between 6 and 8 years old.
Collapse
|
8
|
Hong P, Zhao X, Liu R, Rai S, Song Y, Xu R, Li J. Perthes Disease in a Child With Osteogenesis Imperfecta From a Rare Genetic Variant: A Case Report. Front Genet 2022; 13:920950. [PMID: 35873455 PMCID: PMC9304686 DOI: 10.3389/fgene.2022.920950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 06/06/2022] [Indexed: 12/02/2022] Open
Abstract
Background: Although certain genetic components have been reported as contributing factors for Perthes disease, its etiology remains unclear. We present a rare case of Perthes disease in a child with osteogenesis imperfecta (OI) caused by a mutation in the COL1A1 gene (NM_000088):exon25:c.1726C>T, (p.Gln576X). Case presentations: A 7-year-old boy was initially treated at our medical facility in March 2016 with a history of chronic pain in right hip joint and limping for a year. He was diagnosed as Perthes disease in the right hip joint. He underwent acetabular osteotomy and ipsilateral proximal femoral varus osteotomy for better containment. During the follow-ups, the right hip demonstrated a normal range of motion without pain, and the pelvic X-ray demonstrated Stulberg Type II hip joint with a round femoral head. In the latest admission in 2022, he suffered from a right femoral shaft fracture after petty violence. After reviewing his medical history, he was suspected of having OI. The whole exome sequencing demonstrated a gene mutation in COL1A1 (OMIM 166200) and confirmed the diagnosis of OI. Telescopic nailing was used to treat the femoral shaft fracture. After the nailing of the right femur, the appearance of the lower extremity seemed normal and symmetrical. Conclusion: This study revealed that there might be an association between OI and Perthes disease. Our case report enriches the phenotypes of osteogenesis imperfecta and provides insight into the pathogenesis of LCPD.
Collapse
Affiliation(s)
- Pan Hong
- Department of Orthopaedic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaolong Zhao
- Department of Orthopaedics, First Hospital of Wuhan, Wuhan, China
| | - Ruikang Liu
- Department of Endocrinology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Saroj Rai
- Department of Orthopaedics and Trauma Surgery, Karama Medical Center, Dubai, United Arab Emirates
| | - Yingying Song
- Medical Department of Hubei University of Science and Technology, Xianning, China
| | - Ruijing Xu
- Department of Orthopaedic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- *Correspondence: Ruijing Xu, ; Jin Li,
| | - Jin Li
- Department of Orthopaedic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- *Correspondence: Ruijing Xu, ; Jin Li,
| |
Collapse
|
9
|
Operative Management of Avascular Necrosis of the Femoral Head in Skeletally Immature Patients: A Systematic Review. Life (Basel) 2022; 12:life12020179. [PMID: 35207467 PMCID: PMC8879936 DOI: 10.3390/life12020179] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 01/12/2022] [Accepted: 01/21/2022] [Indexed: 12/11/2022] Open
Abstract
Purpose: Osteonecrosis of the femoral head (ONFH) is common in skeletally immature patients. The management of ONFH is controversial, with limited evidence and unpredictable results. This study systematically reviewed the current operative modalities and clinical outcomes of surgical management for ONFH in skeletally immature patients. Methods: The present study was conducted according to the PRISMA 2020 guidelines. PubMed, Google Scholar, Embase, and Web of Science databases were accessed in October 2021. All the published clinical studies reporting data concerning the surgical management of ONFH in skeletally immature patients were included. Results: This review included 122 patients (127 hips). 38.2% (46 of 122) were female. The mean age of the patients was 14.2 ± 2.3 years. The mean duration of the follow-up was 55.3 ± 19.6 months. The Harris Hip Score improved from 68.8 ± 11.9 at baseline to 90.5 ± 6.5 at last follow-up (p < 0.0001). Femoral head collapse and secondary hip degeneration were the most common complications. Conclusion: Several surgical techniques are available and effective for the management of ONFH in skeletally immature patients. This study evidenced high heterogeneity of the surgical procedures and eligibility criteria. Further high-quality investigations are required to establish proper indications and surgical modalities.
Collapse
|