Legg-Calvé-Perthes Disease

Proximal femoral varus osteotomy for Legg-Calvé-Perthes disease: Do age and lateral pillar classifications influence short-to-mid-term clinical and radiological outcomes?

INTRODUCTION

Proximal femoral varus osteotomy (FVO) is one of the most used treatment methods with acceptable outcomes for Legg-Calvé-Perthes disease (LCPD). We aimed to investigate the influence of age at disease onset and the Lateral Pillar classification on clinical and radiological outcomes of FVO surgery LCPD patients between 6-12years of age.

HYPOTHESIS

Proximal FVO surgery in the early fragmentation phase of LCPD patients led to acceptable clinical and radiographic outcomes in a 3-year follow-up, regardless of preoperative age and Herring type.

MATERIAL AND METHODS

Fifty patients with LCPD (Herring groups B, B/C, and C) who underwent FVO were retrospectively reviewed. We evaluated radiological [center-edge angle, extrusion index, epiphyseal index, acetabular index, articulo-trochanteric distance (ATD)] and clinical [hip abduction range of motion (ROM), Trendelenburg sign, pain, and Harris hip score (HHS)] outcomes with a follow-up of 37.3±10.5months (range: 24-180months). Finally, the overall treatment outcome was assessed using the Stulberg classification.

RESULTS

The ROC curve analysis did not reveal any significant relationship between age and clinical or radiological outcomes, and there was no predictable age cut-off for surgical outcomes (p=0.13). No significant difference was found in Stulberg classification at the follow-up between patients with type B, B/C, and C of the lateral pillar (p>0.05).

DISCUSSION

Our results demonstrated that open-wedge proximal FVO surgery in the early fragmentation phase of LCPD patients led to acceptable clinical and radiographic outcomes in a 3-year follow-up. Each sample of our study was very small and a lot of variables were measured, making this result not adequately strong enough to draw a robust conclusion. However, FVO surgery remains a possible suggestion for patients in the early fragmentation phase, and age and lateral pillar type may not be limiting factors.

LEVEL OF EVIDENCE

IV; therapeutic retrospective cohort.

A Comparison Between 3 Functional Hip Scores for Evaluation of the Pediatric Hip

BACKGROUND

This investigation aimed to determine the degree of correlation among 3 functional scales for evaluating the hip in pediatric patients and determine the correlation between measures of global function and outcome.

METHODS

We performed a prospective study of 173 consecutive patients (M age = 13 ± 3 y) being followed for developmental dysplasia of the hip (n = 122, 71%), slipped capital femoral epiphysis (n = 31, 18%), or Legg-Calve-Perthes disease (n = 20, 12%). We evaluated patients clinically, and we compiled scores for the Iowa Hip Score (IHS), Harris Hip Score (HHS), and Children's Hospital Oakland Hip Evaluation Scale (CHOHES). Patients concomitantly completed the Pediatric Outcomes Data Collection Instrument (PODCI) at the same clinic visit. We assessed Global Functioning Scale the and the Sports and Physical Functioning Core Scale of the PODCI. We determined the degree of correlation between the functional hip scales and between each scale and the PODCI scales using Spearman rank correlation coefficients.

RESULTS

The correlations between the IHS, HHS, and CHOHES scores were robust (IHS and HHS ρ = 0.991; IHS and CHOHES ρ = 0.933; HHS and CHOHES ρ = 0.938; all P < 0.001). The correlation between the Global Functioning Scale of the PODCI and the 3 hip scores was ρ = 0.343 for the IHS, ρ = 0.341 for the HHS, and ρ = 0.352 for the CHOHES (all P < 0.001). The correlation between the sports and physical functioning core scale of the PODCI and the 3 hip scores was ρ = 0.324 for the IHS, ρ = 0.329 for the HHS, and ρ = 0.346 for the CHOHES (all P < 0.001).

CONCLUSIONS

In a pediatric population with diverse hip pathology, there was a very strong correlation between scores on the IHS, HHS, and CHOHES. However, none of these 3 most commonly used hip scores correlated strongly with the global functioning scale or sports and physical functioning core scale of the PODCI. The most frequently used scores to determine the outcome of pediatric patients with hip pathology correlate strongly with each other but do not necessarily relate to global functional results.

LEVEL OF EVIDENCE

Level IV.

Advances in experimental models of osteonecrosis of the femoral head

Background

Osteonecrosis of the femoral head (ONFH) is a devastating disease affecting young adults, resulting in significant pain, articular surface collapse, and disabling dysfunction. ONFH can be divided into two broad categories: traumatic and non-traumatic. It has been established that ONFH results from an inadequate blood supply that causes the death of osteocytes and bone marrow cells. Nonetheless, the precise mechanism of ONFH remains to be elucidated. In this regard, preclinical animal and cell models to study ONFH have been established to assess the efficacy of various modalities for preventing and treating ONFH. Nevertheless, it should be borne in mind that many models do not share the same physiologic and metabolic characteristics as humans. Therefore, it is necessary to establish a reproducible model that better mimics human disease.

Methods

We systematically reviewed the literatures in regard to ONFH experimental models over the past 30 years. The search was performed in PubMed and Web of Science. Original animal, cell studies with available full-text were included. This review summarizes different methods for developing animal and cell experimental models of ONFH. The advantages, disadvantages and success rates of ONFH models are also discussed. Finally, we provide experimental ONFH model schemes as a reference.

Results

According to the recent literatures, animal models of ONFH include traumatic, non-traumatic and traumatic combined with non-traumatic models. Most researchers prefer to use small animals to establish non-traumatic ONFH models. Indeed, small animal-based non-traumatic ONFH modeling can more easily meet ethical requirements with large samples. Otherwise, gradient concentration or a particular concentration of steroids to induce MSCs or EPCs, through which researchers can develop cell models to study ONFH.

Conclusions

Glucocorticoids in combination with LPS to induce ONFH animal models, which can guarantee a success rate of more than 60% in large samples. Traumatic vascular deprivation combines with non-traumatic steroids to induce ONFH, obtaining success rates ranging from 80% to 100%. However, animals that undergo vascular deprivation surgery may not survive the glucocorticoid induction process. As for cell models, 10-6mol/L Dexamethasone (Dex) to treat bone marrow stem cells, which is optimal for establishing cell models to study ONFH.

The translational potential of this article

This review aims to summarize recent development in experimental models of ONFH and recommended the modeling schemes to verify new models, mechanisms, drugs, surgeries, and biomaterials of ONFH to contribute to the prevention and treatment of ONFH.

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.

A Review of Abductor Tendon Tears: The Hidden Lesion of the Hip

»

Greater trochanteric pain syndrome consists of a group of associated conditions involving the lateral hip that can be debilitating to patients, mostly women between ages 40 and 60 years.

»

Abductor tendon tears are becoming a more recognized cause of lateral hip pain in patients without hip osteoarthritis.

»

Diagnosis of this condition is critical to patient care because misdiagnosis often leads to unnecessary prolonged pain and even unnecessary procedures that address different pathologies.

»

Treatment strategies consists of nonoperative modalities such as nonsteroidal anti-inflammatory medications, corticosteroid injections, and physical therapy, but for refractory cases, surgical techniques including repair, augmentation, and reconstruction have been well-described in the literature providing patients with acceptable outcomes.

Outcomes in Pediatric Hip FAI Surgery: a Scoping Review

PURPOSE OF REVIEW

Femoracetabular impingement (FAI) is a common source of hip pain in children and adolescents. While nonoperative therapies and open surgical procedures can be effective, hip arthroscopy is a minimally invasive treatment option with substantial benefit. The purpose of this paper is to evaluate the current role of hip arthroscopy in treating FAI within the pediatric population. This article examines its efficacy through a review of hip arthroscopy outcomes in the contemporary orthopaedic literature.

RECENT FINDINGS

Morphologic changes in the acetabulum and proximal femur seen in FAI can be attributed to a multitude of etiologies-including idiopathic FAI, Legg-Calve-Perthes, and slipped capital femoral epiphysis. In general, arthroscopic treatment of FAI secondary to these conditions leads to statistically significant improvements in pain and patient-reported outcomes in the short and long term. In the pediatric athlete, repetitive stress on the hip perpetuates FAI and can drastically hinder performance. Hip arthroscopy allows for a high rate of return to sport with minimal morbidity in this population. Overall, pediatric hip arthroscopy is effective in treating FAI secondary to a wide variety of conditions. Despite its clinical benefits, patients and their families should be counseled regarding alternative treatments, potential complications, and return to play.

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.

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.

Association of MTHFR rs1801133 and homocysteine with Legg-Calvé-Perthes disease in Mexican patients

Background

Legg–Calvé–Perthes disease (LCPD) is the avascular osteonecrosis of the proximal femoral epiphysis. It is a rare disease of unclear etiology in children, although alterations in coagulation or the collagen gene have been described and could be associated with its etiology. Our objective was to evaluate the following alterations: COL1A1 (rs1107946, rs2412298), COL2A1 (rs121912891 and rs387106558), MTHFR rs1801133, CBS rs115742905, and PT rs1799963 and their relationship with LCPD.

Methods

DNA was obtained and genotyped by real-time PCR with TaqMan probes. Prothrombin (FII) and homocysteine (Hcy) were determined by a coagulometric method. The variables were described as mean and standard deviation or percentages, and genotypic and allelic distributions were analyzed using the Student's t-test. The Hardy–Weinberg equilibrium and OR were also used.

Results

We studied 23 patients with LCPD and 46 controls. We did not find any association of the MTHFR, CBS, PT, COL1A1, and COL2A1 genetic variants with LCPD. However, when adjusting the data with the Hcy values for the MTHFR C677T polymorphism, the C/C genotypes showed an association with the recessive model (p = 0.038), with susceptibility to LCPD.

Conclusion

No association was found with the CBS, PT, COL1A1, and COL2A1 genes. Nevertheless, our results suggest a significant link between moderately elevated Hcy levels and the MTHFR C677T polymorphism in a cohort of Mexican children with LCPD.

Co-occurrence of Blount's disease and Legg-Calvé-Perthes disease: is obesity a factor?

Legg-Calvé-Perthes disease (LCPD) and Blount's disease share a similar presenting age in addition to similar symptoms such as limp or knee pain. A little overlap is mentioned about both diseases. We sought to present cases of children having both conditions to discuss the implications of this co-occurrence on diagnosis and management. After institutional review board approval, we retrospectively reviewed records of four children who developed both Blount's disease and LCPD. Patient details and outcomes were analyzed. Radiographs were evaluated for the lateral pillar classification, Stulberg classification, tibial metaphyseal-diaphyseal angle and tibiofemoral angle. Two of the cases were initially diagnosed with Blount's disease and subsequently developed Perthes, one case presented initially with both disorders and the final case had Perthes followed by Blount's. Three children were obese and one was overweight. The common symptom to all patients was an abnormal gait, which was painless in two children and painful in two. Blount's disease required surgery in three children. Radiographs showed Lateral Pillar B, B/C border and C hips, and the final Stulberg was stage II (n = 2) or stage IV (n = 2). Obesity is associated with Blount's disease and LCPD, so obese children can be at an increased risk of developing both disorders. Therefore, a child with Blount's disease who has persistent, recurrent or worsening symptoms such as gait disturbance or thigh or knee pain might benefit from a careful physical exam of the hips to prevent a delayed or even missed LCPD diagnosis.

Operative Management of Avascular Necrosis of the Femoral Head in Skeletally Immature Patients: A Systematic Review

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.

Can large doses of glucocorticoids lead to Perthes? a case report and review of the literature

Background

Perthes disease (Legg-Calvé-Perthes, LCP) is a self-limited and non-systemic disease occurring in the femoral heads of children, which is mainly manifested as an ischemic necrosis of the femoral head epiphysis, leading to subchondral ossification injury of the femoral head.

Case presentation

Here we report a case of 11-year-old child with long-term use of high-dose glucocorticoids. With MRI examination finding the epiphyseal necrosis of right humeral head, femur and tibia, and X-ray examination finding bilateral femoral head necrosis, the child was diagnosed as Perthes disease based on his clinical and imaging data.

Conclusions

Long-term and high-dose glucocorticoids may be one of the causes of Perthes disease.

Legg-Calvé-Perthes disease following Ender nail fixation of a pediatric femoral fracture

Introduction and importance

Legg–Calvé–Perthes disease (LCPD) sometimes occur in children, however it is difficult to diagnose it at the early stage especially in the cases there are no complaints of symptoms. Femoral shaft fractures in children cause various complications such as leg-length discrepancy, nonunion and malunion, refracture, and osteonecrosis of the femoral head. We presented a rare case in which a pediatric patient developed LCPD after femoral shaft fracture.

Case presentation

A healthy 8-year-old boy sustained a left femoral diaphyseal fracture following a pedestrian car accident. Fixation was achieved using retrograde Ender nails; bone union was confirmed at 3 months postoperatively, and the Ender nails were removed at 8 months postoperatively without any problems. Unfortunately, the morphological change of the ipsilateral femoral head and subtle symptoms were missed until the femoral head collapsed. LCPD was successfully treated with intertrochanteric varus osteotomy, which achieved a good clinical result.

Clinical discussion

Although the reason for the ipsilateral LCPD after the femoral shaft fracture is unclear, this case highlights the need for close postoperative follow-up of pediatric femoral fractures resulting from high-energy trauma to prevent the misdiagnosis of this coincidental complication.

Conclusion

This case report describes a missed ipsilateral LCPD after a femoral diaphyseal fracture caused by high-energy trauma. Close postoperative follow-up with a detailed assessment and vigilant interpretation of postoperative radiography is imperative to avoid delayed/missed diagnosis of conditions for which early management may provide better outcomes.

•

Legg–Calvé–Perthes disease after femoral shaft fracture

•

Close postoperative radiographic follow-up is necessary to avoid misdiagnosis.

•

Legg–Calvé–Perthes disease was successfully treated with intertrochanteric varus osteotomy.

Design and implementation of an acute Trauma and Orthopaedic ePlatform (TOP) referral system utilising existing secure technology during the COVID-19 pandemic

Introduction

Virtual fracture clinics (VFCs) are being increasingly used to offer safe and efficient orthopaedic review without the requirement for face-to-face contact. With the onset of the COVID-19 pandemic, we sought to develop an online referral pathway that would allow us to provide definitive orthopaedic management plans and reduce face-to-face contact at the fracture clinics.

Methods

All patients presenting to the emergency department from 21March 2020 with a musculoskeletal injury or potential musculoskeletal infection deemed to require orthopaedic input were discussed using a secure messaging app. A definitive management plan was communicated by an on-call senior orthopaedic decision-maker. We analyzed the time to decision, if further information was needed, and the referral outcome. An analysis of the orthopaedic referrals for the same period in 2019 was also performed as a comparison.

Results

During the study period, 295 patients with mean age of 7.93 years (standard error (SE) 0.24) were reviewed. Of these, 25 (9.8%) were admitted, 17 (5.8%) were advised to return for planned surgical intervention, 105 (35.6%) were referred to a face-to-face fracture clinic, 137 (46.4%) were discharged with no follow-up, and seven (2.4%) were referred to other services. The mean time to decision was 20.14 minutes (SE 1.73). There was a significant difference in the time to decision between patients referred to fracture clinic and patients discharged (mean 25.25 minutes (SE 3.18) vs mean 2.63 (SE 1.42); p < 0.005). There were a total of 295 referrals to the fracture clinic for the same period in 2019 with a further 44 emergency admissions. There was a statistically significant difference in the weekly referrals after being triaged by the VFC (mean 59 (SE 5.15) vs mean 21 (SE 2.17); p < 0.001).

Conclusion

The use of an electronic referral pathway to deliver a point of care virtual fracture clinic allowed for efficient use of scarce resources and definitive management plan delivery in a safe manner.

Cite this article: Bone Joint Open 2020;1-6:293–301.

Idiopathic Avascular Necrosis of Trapezoid in Adolescence: 3-Year Follow-Up

Avascular necrosis (AVN) is relatively uncommon in the carpal bones, although it most frequently involves the lunate and scaphoid. The trapezoid has abundant vascular channels from a rich network of dorsal and palmar vessels, and only a few cases of AVN have been reported in adults who sustained a traumatic insult. We present a rare case of idiopathic AVN of the trapezoid in an adolescent presenting with refractory pain at the second metacarpal base. Over a period of 36 months, follow-up symptom evaluations and serial magnetic resonance images showed prominent gradual improvement, consistent with spontaneous resolution.

Developmental Dysplasia of the Hip with Concurrent Legg-Calvé-Perthes Disease in the Contralateral Hip

Developmental dysplasia of the hip (DDH) is a common hip disorder in pediatrics; about one in 100 newborns has it due to dysplasia and one to two per 1000 have it due to dislocation. Some factors are responsible for the disease, and breech presentation has been identified as a major risk factor. It might be associated with other conditions too. Patients with Legg-Calvé-Perthes disease present with painless limping gait with idiopathic etiology; it is unilateral in most of the cases. This paper reported a rare scenario of DDH associated with concurrent contralateral Legg-Calvé-Perthes disease.

A 5-year-old Saudi male patient, known case of developmental dysplasia of the right hip, which was managed operatively at a different hospital, presented in our outpatients clinic for right hip dysplasia and was found incidentally as having a limping gait due to left hip limited range of motion, following clinical assessment, pelvic radiographs demonstrated presence of subluxation at the right hip in addition to sclerosis, and irregularity of the left femoral head epiphysis. Right pelvic Dega osteotomy, femoral derotation osteotomy, varus osteotomy, and left hip arthrogram was examined under anesthesia with the positioning of the left hip at 45 degrees of abduction and 30 degrees of flexion to achieve the best coverage. Hip spica application was performed to correct DDH of the right hip. Repeated radiography at the subsequent visits showed better coverage of the femoral head on the right side. During a routine follow-up, there were also some osteonecrotic changes of the left femoral head that confirmed the diagnosis of left Legg-Calvé-Perthes disease.

Perthes disease: A new finding in Floating-Harbor syndrome

Floating-Harbor Syndrome (FHS; OMIM #136140) is an ultra-rare autosomal dominant genetic condition characterized by expressive language delay, short stature with delayed bone mineralization, a triangular face with a prominent nose, and deep-set eyes, and hand anomalies. First reported in 1973, FHS is associated with mutations in the SRCAP gene, which encodes SNF2-related CREBBP activator protein. Mutations in the CREBBP gene cause Rubinstein-Taybi Syndrome (RSTS; OMIM #180849, #613684), another rare disease characterized by broad thumbs and halluces, facial dysmorphisms, short stature, and intellectual disability, which has a phenotypic overlap with FHS. We describe a case of FHS associated with a novel SRCAP mutation and characterized by Perthes disease, a skeletal anomaly described in approximately 3% of patients with RSTS. Thus Perthes disease can be added to the list of clinical features that overlap between FHS and RSTS.