Total Hip Arthroplasty in Patient with the Sequelae of Legg-Calvé-Perthes Disease

Approaching total hip arthroplasty after Legg-Calvé-Perthes disease: A case series and literature review

Due to femoral head-neck deformities and hip joint incongruence, patients with Legg-Calvé-Perthes Disease (LCPD) commonly require total hip arthroplasty (THA) in the fifth and sixth decades of life. These patients present additional challenges to arthroplasty surgeons not only because of their complicated hip anatomy but also because patients may have undergone prior operative procedures in childhood and thus present with pre-existing proximal femoral deformities. THA in LCPD patients can be associated with peri-operative complications such as fracture or nerve injury, and the rate of reoperation has been reported to be higher in the LCPD population as compared to the general population undergoing THA. Despite this, multiple case reports and studies have shown the relative long-term success of THA in patients with history of LCPD. In particular, uncemented modular stems are a commonly used implant choice in such cases. This article reviews and discusses the technical considerations for THA in patients with LCPD and highlights three such cases.

Outcome and complication rate of total hip arthroplasty in patients younger than twenty years: which bearing surface should be used?

PURPOSE

Total hip arthroplasty (THA) in younger patients remains controversial due to concerns regarding long-term implant survival and potential complications. This study aimed to evaluate long-term clinical outcomes, complications, differences in complication and revision rates by bearing surfaces, and Kaplan-Meier survival curves for THA in patients under 20 years old.

METHODS

A retrospective review was conducted for 65 patients (78 hips) who underwent THA between 1991 and 2018. Their mean age was 18.9 years. Their clinical outcomes were assessed using the Harris Hip Score (HHS). Radiological outcomes were evaluated based on the presence of loosening, osteolysis, and heterotopic ossification. Complications such as dislocation, periprosthetic fractures, and infections were assessed. The mean follow-up period was 13.2 years (range, 5.0-31.2 years).

RESULTS

The mean HHS improved from 44.6 to 90.1. There were two cases of dislocation. However, no periprosthetic fracture, deep infection, or ceramic component fracture was noted. There were 19 revisions of implants. Eighteen of 19 hips were operated with hard-on-soft bearings in the index surgery (p < 0.01). The 23-year survivorship was 97.8% for THA using ceramic-on-ceramic bearings, while the 31-year survivorship was 36.7% using hard-on-soft bearings.

CONCLUSION

THA in patients under 20 years old yielded promising clinical and radiological outcomes, although polyethylene-bearing-related concerns persisted. Previously operated patients with hard-on-soft bearing should be meticulously examined during the follow-up. As ceramic-on-ceramic bearing showed excellent survivorship in this particular cohort, we recommend the use of this articulation as the bearing of choice.

Arthroscopic Femoral Head Allograft With Proximal Femoral/Periacetabular Osteotomies for Sequelae of Perthes: A Case Report

CASE

We describe the unique case of a 20-year-old man with a history of Legg-Calve-Perthes disease, hip dysplasia, and osteochondral fragmentation of the medial femoral head. We performed arthroscopic femoroplasty and femoral head allografting, followed by a valgus-producing derotational femoral osteotomy (DFO) and periacetabular osteotomy (PAO). At 1-year follow-up, the patient achieved osseous union and complete femoral head healing with return to his active hobbies.

CONCLUSION

We describe the successful utilization of arthroscopic allografting for medial femoral head osteochondral fragmentation. To our knowledge, this is the first report on femoral head arthroscopic allografting before DFO and PAO.

The Validation of Two-Dimensional and Three-Dimensional Radiographic Measurements of Host Bone Coverage in Total Hip Arthroplasty for Hip Dysplasia: A Comparison with Intra-Operative Measurements

Several methods have been introduced to measure the host bone coverage of the acetabular component after total hip arthroplasty (THA). The aims of this study were (1) to validate two-dimensional- and three-dimensional-based host bone coverage measurements by comparing intra-operative measurements, and (2) to determine the minimum host bone coverage for achieving stable cup fixation after THA in hip dysplasia. The clinical outcomes of each patient were evaluated during their final follow-up period using the Harris Hip score (HHS). The coverage of the host bone was analyzed by comparing 2D-based, 3D-based, and intraoperative assessments. The mean HHS was increased significantly from 60.84 ± 14.21 pre-operatively to 93.13 ± 4.59 (p < 0.0001). The host bone coverage ratio measured intraoperatively was 83.67 ± 3.40%, while the ratio measured by 3D CT reconstruction was 82.72 ± 3.59%. There was a strong positive correlation between the intra-operative host bone coverage and the 3D-based one (r = 0.826, p < 0.0001). It is recommended that 3D-based measurements are used to evaluate the host bone coverage after THA in patients with hip dysplasia. In addition, achieving a minimum host bone coverage of 75% is recommended for the attainment of stable cup fixation.

Total hip arthroplasty through the direct anterior approach for sequelae of Legg-Calvé-Perthes disease

INTRODUCTION

Due to multiplanar deformities of the hip, total hip arthroplasty (THA) for sequelae of Legg-Calvé-Perthes disease (LCPD) is often technically demanding. This study aimed to compare the clinical and radiographic outcomes of patients with sequelae of LCPD undergoing THA through the direct anterior approach (DAA) and non-anterior approaches to the hip.

METHODS

All patients with sequelae of LCPD who underwent primary THA between 2004 and 2018 (minimum follow-up: 2 years) were evaluated and separated into two groups: THA through the DAA (Group AA), or THA through non-anterior approaches to the hip (Group non-AA). Furthermore, a consecutive control group of patients undergoing unilateral THA through the DAA for primary hip osteoarthritis (Group CC) was retrospectively reviewed for comparison.

RESULTS

Group AA comprises 14 hips, group non-AA 17 hips and group CC 30 hips. Mean follow-up was 8.6 (± 5.2; 2-15), 9.0 (± 4.6; 3-17) and 8.1 (± 2.2; 5-12) years, respectively. At latest follow-up, Harris Hip Score was 90 (± 20; 26-100), 84 (± 15; 57-100), and 95 (± 9; 63-100) points, respectively. Overall, 6 patients treated for LCPD (each 3 patient in the AA and non-AA group) developed postoperative sciatic nerve palsy, of which only one was permanent. Complication-related revision rate at the latest follow-up was 15% in the AA-group and 25% in the non-AA group, respectively.

CONCLUSION

THA through the DAA might be a credible option for the treatment of sequelae of LCPD with comparable complication rates and functional outcomes to non-anterior approaches.

Relative Femoral Neck Lengthening in Legg-Calvé-Perthes Total Hip Arthroplasty

Background

Total hip replacement (THR) in patients with a history of Legg-Calvé-Perthes disease can be a technically challenging procedure due to the distorted hip morphology. We propose a technique in which THR is preceded by a modified relative femoral neck lengthening (RFNL) procedure. Hereby, we aim to restore the biomechanical parameters.

Methods

Twenty-eight patients underwent RFNL in preparation of a second-stage THR between December 2011 and September 2019. The mean age was 38.1 ± 11.4 years. Radiographs were analyzed for centrotrochanteric distance, lateral displacement of the greater trochanter, and leg length discrepancy to assess the biomechanical restoration. Complication rate, reoperation rate, and patient-reported outcome measures were measured.

Results

Mean centrotrochanteric distance increased from −18.7 ± 6.7 mm preoperatively to 1.9 ± 9.0 mm (P < .001) after RFNL and to 11.4 ± 10.4 mm after THR (P < .001). Mean lateral displacement of the greater trochanter increased from 34.2 ± 8.1 mm preoperatively to 42.4 ± 5.2 mm (P < .001) after RFNL and to 49.9 ± 8.3 mm after THR (P < .001). Leg length discrepancy decreased from 17.5 ± 10.5 mm to 2.7 ± 2.2 mm after THR (P < .001). Mean Harris Hip Score improved from 56.9 ± 17.6 preoperatively to 89.4 ± 10.7 at the latest follow-up (P < .001). Eight patients (8 hips) postponed THR because of sufficient clinical improvement, at a mean follow-up of 4.2 ± 2.1 years. Two hips needed a revision RFNL due to non-union (7.1%), and 1 hip replacement was revised due to a deep infection (5.0%).

Conclusions

RFNL prior to THR in patients with end-stage osteoarthritis following Legg-Calvé-Perthes disease allows for utilizing regular implants with straight access to the femoral canal, with restored biomechanics and restoration of leg length. The prominent overhanging greater trochanter is reduced to prevent postoperative extra-articular impingement.

Artroplastia total do quadril não cimentada em pacientes com osteoartrose secundária à doença de Legg-Calvé-Perthes em comparação com a osteoartrose primária: Um estudo caso-controle

Objective  To perform a comparative clinical, functional and radiographic evaluation of total hip arthroplasty (THA) performed with a cementless prosthesis in cases of osteoarthrosis secondary to Legg-Calvé-Perthes Disease (LCPD) and in cases of primary osteoarthrosis.

Methods  In the present case-control study, we reviewed medical records of patients admitted to a university hospital between 2008 and 2015 to undergo THA due to LCPD sequelae and compared them with a control group of patients who underwent the same surgery due to primary hip osteoarthrosis. We recruited patients for clinical, functional, and radiographic analysis and we compared the evaluations in the immediate postoperative period and at the last follow-up visit, considering surgical time, size of prosthetic components, and complications.

Results  We compared 22 patients in the study group (25 hips) with 22 patients (25 hips) in the control group, all of whom had undergone THA with the same cementless prosthesis. There was greater functional impairment in the group of patients with LCPD sequelae ( p  = 0.002). There were 4 intraoperative femoral periprosthetic fractures in the LCPD group and none in the primary osteoarthrosis group ( p  = 0.050).

Conclusions  There is an increased risk of intraoperative periprosthetic femoral fracture and worse clinical-functional results in patients undergoing cementless THA due to osteoarthrosis secondary to LCPD sequelae than in those who have undergone the same surgery due to primary hip osteoarthrosis.

Imageless Navigation Improves Intraoperative Monitoring of Leg Length Changes during Total Hip Arthroplasty for Legg-Calve-Perthes Disease: Two Case Reports

Legg-Calve-Perthes disease is a rare condition characterized by avascular necrosis and malformation of the femoral head. For many patients, total hip arthroplasty (THA) is the only viable treatment option; however, there are challenges associated with THA in this population, primarily the equalization of leg lengths. Here, we present two cases of Legg-Calve-Perthes disease treated via total hip arthroplasty with the assistance of an imageless, computer-assisted navigation device. In each case, the device provided intraoperative data on leg length in real time, allowing for improved accuracy of component placement. Postoperative leg lengths were confirmed to be equalized in each case using radiographs. These cases are, to our knowledge, the first such cases using imageless navigation during THA and demonstrate the benefits of such assistive technologies in challenging cases such as Legg-Calve-Perthes disease.

Primary Total Hip Arthroplasty for Legg-Calvé-Perthes Syndrome: 20 Year Follow-Up Study

BACKGROUND

Patients with Legg-Calvé-Perthes Syndrome (LCPS) are at an increased risk for developing osteoarthritis of the hip and undergoing total hip arthroplasty (THA) at an early age. Importantly, this younger age may put them at a higher risk for failure and revision surgery. The purpose of the study was to assess the clinical and radiographic outcomes as well as implant failure rate and risk for revision surgery at an average 20 years follow up.

METHODS

Data from LCPS patients treated with THA were collected including age, gender, operative date, revision date, as well as reason for and type of revision. Living patients filled the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaires at the time of last follow-up. Radiographs were evaluated for lucencies, debonding, loosening, osteolysis, wear, heterotopic ossification and sclerosis.

RESULTS

Nineteen patients (20 hips) treated with THA were followed-up for a mean of 18.3 years (range, 10.1 - 36.2 years). Radiographic evidence of lucency of the acetabular component was seen in 70% of the patients and femoral cortical hypertrophy in 85% at last follow-up. The rate of revision for any reason was 35%, mostly due to aseptic acetabular loosening.

CONCLUSIONS

Our findings support the use of THA for the treatment of OA in patients with LCPS, bearing in mind the potentially lower survival rate at 20 years as compared those treated with THA for primary OA. Further studies are needed to identify the possible causes of the high rate of cortical hypertrophy seen in this patient population.Level of Evidence: IV Therapeutic.

Monobloc implants in cementless total hip arthroplasty in patients with Legg-Calve-Perthes disease: a long-term follow-up

BACKGROUND

The purpose of this study was to evaluate 10-year outcomes in cementless monobloc total hip arthroplasty (THA) in a group of hips with Legg-Calve-Perthes disease (LCPD).

METHODS

We reviewed 71 patients (88 hips) who underwent cementless THA with a diagnosis of LCPD from 2003 to 2009. From the total of 71 patients, 34 men and 37 women with an average age of 49.94 years were included. The mean follow-up period was 10 years.

RESULTS

The mean Harris Hip Score improved significantly from 46.42 to 89.70. Similarly, the postoperative range of motion, hip dysfunction and osteoarthritis outcome score and SF-12 score also significantly improved. The mean leg lengthening was 22.1 mm. During the follow-up, eight complications were noted, including two cases of intraoperative femoral fractures, two cases of sciatic nerve paralysis, two cases of heterotrophic ossifications, one case of thigh pain and one case of dislocation. One revision was conducted for a periprosthetic fracture, and the survivorship at 10 years was 98.3%.

CONCLUSIONS

These data suggest that the monobloc stem can lead to satisfactory outcomes for clinical function, radiological evaluation, restoration of the normal limb lengths, complications, and survivorship among LCPD patients undergoing total hip arthroplasty.

Systematic review of the outcome of total hip arthroplasty in patients with sequelae of Legg-Calvé-Perthes disease

BACKGROUND

Total hip arthroplasty (THA) in patients with sequelae of Legg-Calvé-Perthes disease (LCP) is technically demanding because of the disease related deformities occuring in the proximal femur and/or the multiplanar deformities secondary to corrective osteotomies in childhood. Little is known about the long-term outcome of the procedure in this challenging group of patients.

METHODS

We carried out a systematic review of the literature to determine the functional outcome, complications and revision rate of THA in patients with sequelae of LCP disease. Six out of 148 potential studies involving 245 hips met the inclusion criteria. The mean age was 45.7 years (19-74) and follow-up was 8.4 years (2-21).

RESULTS

There were 221 cementless THAs (90%), 22 hybrid THAs (9%) and 2 cemented THAs (1%). The femoral components used included 187 standard stems (76%), 43 modular stems (18%) and 15 custom-made stems (6%). The modular implants used were reamed S-Rom stems. All studies reported a significant improvement in hip function following THA. There were 16 revision THAs (7%) occurring at a mean of 7.5 years (0.4-10.3). Complications included intra-operative fracture (11%, n = 27), aseptic loosening (5%, n = 13), sciatic nerve palsy (3%, n = 7) and heterotopic ossification (2%, n = 4). All intra-operative fractures occurred when standard femoral stems were used. The average limb lengthening in the patients with a post-operative sciatic nerve injury was 1.9 cm. All patients with this complication had a history of previous hip surgery.

CONCLUSIONS

THA in patients with LCP disease results in similar functional outcome compared to patients with primary osteoarthritis; however, the revision rate at mid-term follow-up is slightly increased. Reamed modular (S-Rom) and custom femoral implants appear to be associated with a decreased risk of intra-operative fracture. Care should be taken when addressing leg length discrepancy in this group of patients due to the increased risk of sciatic nerve palsy, especially in patients with prior surgical procedures.