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.

Treatment of Symptomatic Residual Deformity in Legg-Calvé-Perthes Disease: Mid-Term Outcomes and Predictors of Failure After Surgical Hip Dislocation with Femoral-Head Reshaping and Relative Neck Lengthening

BACKGROUND

Treating patients with symptomatic hips after healed Legg-Calvé-Perthes disease (LCPD) is challenging, mainly because of the complexity of the deformity. We performed a retrospective study to evaluate clinical and radiographic outcomes, measure the survival rate, and identify predictors of failure following a surgical hip dislocation (SHD) with femoral-head reshaping and relative femoral-neck lengthening for the treatment of symptomatic residual hip deformity after healed LCPD.

METHODS

We identified 60 patients undergoing SHD for the treatment of symptomatic residual LCPD deformity. Fifty-one (85%) of the patients (mean age, 16.3 ± 4.7 years; 21 male patients [41%]), were followed ≥4 years after surgery. We defined surgical failure as conversion to, or recommendation for, total hip arthroplasty (THA) or a Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain score of ≥10 at the most recent follow-up. We used a multivariable Cox proportional hazards model to identify factors that were predictive of failure. The rate of survival free from failure was estimated using a Kaplan-Meier curve.

RESULTS

Twenty (39%) of the patients met 1 of the end-point criteria for surgical failure, while the hips of the remaining 31 (61%) of the patients were successfully preserved at a median follow-up of 10.2 years (interquartile range, 5.7 to 12.9 years). The estimated survival was 80% (95% confidence interval [CI] = 70% to 92%) at 5 years and 66% (95% CI = 53% to 81%) at 10 years. Independent factors associated with surgical failure were the severity of preoperative pain as assessed by the WOMAC pain score (hazard ratio [HR] = 1.16; 95% CI = 1.03 to 1.30; p = 0.01) and the severity of the deformity as assessed by the anteroposterior alpha angle (HR = 1.06; 95% CI = 1.01 to 1.11; p = 0.01).

CONCLUSIONS

We found that SHD with relative femoral-neck lengthening and osteochondroplasty of the femoral head-neck junction was associated with improved deformity as assessed radiographically and decreased pain and symptoms of stiffness among patients with symptomatic residual LCPD deformity. Preoperative pain and deformity were identified as predictors of surgical failure. Further research is needed to establish the role of SHD and other procedures in preserving the hip over the long term.

LEVEL OF EVIDENCE

Therapeutic L evel IV . See Instructions for Authors for a complete description of levels of evidence.

Legg-Calve-Perthes' disease: an opportunity to prevent blindness?

Legg-Calve-Perthes' disease (LCP) is defined as avascular necrosis of the femoral head in a child and may present to a variety of disciplines from general practice to orthopaedics, paediatrics, rheumatology and more. The Stickler syndromes are a group of disorders of type II, IX and XI collagen associated with hip dysplasia, retinal detachment, deafness and cleft palate. The pathogenesis of LCP disease remains an enigma but there have been a small number of cases reporting variants in the gene encoding the α1 chain of type II collagen (COL2A1). Variants in COL2A1 are known to cause type 1 Stickler syndrome (MIM 108300, 609508), which is a connective tissue disorder with a very high risk of childhood blindness, and it is also associated with dysplastic development of the femoral head. It is unclear whether COL2A1 variants make a definitive contribution to both disorders, or whether the two are indistinguishable using current clinical diagnostic techniques. In this paper, we compare the two conditions and present a case series of 19 patients with genetically confirmed type 1 Stickler syndrome presenting with a historic diagnosis of LCP. In contrast to isolated LCP, children with type 1 Stickler syndrome have a very high risk of blindness from giant retinal tear detachment, but this is now largely preventable if a timely diagnosis is made. This paper highlights the potential for avoidable blindness in children presenting to clinicians with features suggestive of LCP disease but with underlying Stickler syndrome and proposes a simple scoring system to assist clinicians.

Does transepiphyseal drilling and closure of the greater trochanter in early Legg-Calve-Perthes disease improve natural history?

PURPOSE

There is no consensus regarding treatment of Legg-Calve-Perthes disease (LCPD). The most common sequel of the disease is coxa breva and overgrowth of the greater trochanter (GT). Our purpose was to examine the effectiveness of transepiphyseal drilling combined with closure of the GT apophysis in patients with LCPD.

METHODS

During 2013-2018, we treated 16 consecutive cases of LCPD. Average age was 7.5 (range 6-10) years; nine patients were in early fragmentation, five in late fragmentation and one in reossification stages. Treatment protocol included hip arthrography, percutaneous drilling of the femoral head epiphysis, percutaneous tenotomy of adductor longus and epiphysiodesis of the GT apophysis.

RESULTS

Mean follow-up was 38 months. One patient was lost to follow-up. All patients had a limp prior to surgery. However, at latest follow-up, 10/15 patients had no limp, 11 patients had substantial improvement in hip range of motion. On radiographs, nine patients had Stulberg type 1-2, one type 3 and five type 4-5. There was no change in the epiphysio-trochanteric distance in any patient. Eight out of nine patients treated in the early fragmentation stage had good clinical and radiographic outcome. Most patients treated in late fragmentation stage had Stulberg 4-5 hip and required additional procedures.

CONCLUSIONS

Based on our preliminary experience, our protocol can be effective in the treatment of patients with LCPD in the initial or early fragmentation stages by improving the clinical and radiographic outcomes of the disease. This minimally invasive approach does not compromise any future treatment options.

LEVEL OF EVIDENCE

IV.

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.

Skeletal Maturity in Legg-Calve-Perthes Disease: Significant Discrepancy Present Between the Hand and the Hip

BACKGROUND

The concept of delayed skeletal maturity in Legg-Calve-Perthes Disease (LCPD) has been well identified with the Greulich and Pyle (GP) atlas showing 1 to 2 years delay. Recently the optimized Oxford hip skeletal age (Optimized Oxford) system has been developed and shown to have similar accuracy as the GP atlas for assessing skeletal maturity. However, this system has not been used to assess skeletal maturity in LCPD.

METHODS

A retrospective review of a prospective, multicenter study of patients with LCPD treated from 1984 to 1991 and followed to skeletal maturity was performed. We identified all patients who had a left-hand radiograph at the time of presentation with an accompanying anteroposterior pelvis radiograph including the contralateral hip. Patients were excluded if their age at presentation fell outside the validated range for the Optimized Oxford system. GP atlas was used to determine bone age using left-hand radiographs and the nonaffected hip radiographs were used to calculate the Optimized Oxford bone age. Skeletal maturity indices were compared with chronological age (CA) to determine the discrepancy between methodologies.

RESULTS

A total of 71 patients met inclusion criteria (mean 9.5 ± 1.2 y at presentation, 42.2% females). The mean GP bone age was 1.4 years younger than CA (95% CI: 1.01-1.76 y), with the discrepancy being greater for boys than girls (1.8 vs 0.86 y, P = 0.02). The mean Optimized Oxford bone age was 0.31 years older than CA (95% CI: 0.24-0.38 y) and correlated significantly with CA ( R = 0.97, P < 0.001). There were no sex differences in the Optimized Oxford bone age relative to CA ( P = 0.32). The GP bone age was a mean of 1.7 years younger than the Optimized Oxford bone age (95% CI: 1.35-2.05 y).

CONCLUSION

Skeletal maturity assessment in children with LCPD varies according to the utilized maturity system. The Optimized Oxford bone age more closely mirrors the patient's CA and does not correlate with the GP bone age, which reveals a delayed maturation.

Pediatric Hip Disease Increases the Risk for Opioid Use in Adulthood: Long-term Burden of Pain and Depression

BACKGROUND

Legg-Calvé-Perthes disease (LCPD) and slipped capital femoral epiphysis (SCFE) can result in painful deformation of the hip joint with impaired range of motion and early development of secondary osteoarthritis. It has not been investigated whether having LCPD or SCFE is associated with increased use of pain or antidepressant drug prescriptions later in life.

OBJECTIVE

With this study, we aimed to investigate if patients with a history of LCPD or SCFE have an increased risk of prescription analgesic or antidepressant drugs in adulthood compared with matched controls.

STUDY DESIGN

The included patients were identified by the Swedish Patient Register and matched for age, gender, and residency with 10 control individuals not exposed to any of the mentioned pediatric hip diseases, by the Swedish National Population Register.

SETTING

This was a nationwide, registry-based cohort study which included 1,292 patients diagnosed with LCPD at age 2-15 years and 1,613 patients diagnosed with SCFE at age 5-16 years and > 17 years from 2005 through 2011.

METHODS

Prescription data of first-line analgesic drugs (acetaminophen, nonsteroidal anti-inflammatory drugs, and opioids), or first-line antidepressant drugs (selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and tricyclic antidepressants) were derived from the Swedish Prescribed Drugs Register. Conditional logistic regression models were fitted to estimate the relative risk for the prescription in exposed compared with unexposed individuals. Adjustment was performed for gender and birth year.

RESULTS

In the group with an LCPD diagnosis, the adjusted odds ratio for analgesic prescriptions overall was 1.3 (95% CI, 1.2-1.5). For patients with an SCFE diagnosis, the adjusted odds ratio for analgesic prescriptions overall was 1.4 (95% CI, 1.3-1.6). Among patients with an LCPD diagnosis, the adjusted odds ratio for antidepressant prescriptions overall was 1.0 (95% CI, 0.8-1.2). For patients with an SCFE diagnosis, the adjusted odds ratio was 1.2 (95% CI, 1.1-1.4).

LIMITATIONS

As with all register studies, there are known associated biases such as selection, detection, and observational bias as well as the uncertain quality of input data. Further, the Swedish Prescribed Drugs Register only includes drugs that were prescribed by a physician and dispensed at a pharmacy. This is also a factor that may lead to underestimating the use of acetaminophen and nonsteroidal anti-inflammatory drugs, as these drugs can be acquired "over the counter."

CONCLUSION

During childhood, patients with LCPD or SCFE seem to suffer long-term pain and have an increased risk of requiring analgesic medication in adulthood, including opioids. It is important to assess the causes, type, and severity of pain to optimize pain management to counteract possible overuse in these patients. Seemingly, patients with LCPD do not have an increased risk for antidepressant drug therapy in adulthood whereas we did see an increased risk for that in patients with previous SCFE compared with the general population.

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.

The MRI Effect in Clinical Decision Process in Perthes' Disease: "More Complex Imaging, More Complicated Surgeries"

PURPOSE OF THE STUDY Radiographs are preferred for understanding the deformity and containment in Legg-Calvé-Perthes disease (LCPD), as well as for treatment planning, but plain radiographs provide only static information and are inadequate for dynamic assessment of the joint. Magnetic resonance imaging (MRI) has been shown to be superior to other diagnostic modalities. The aim of this study was to determine the importance of hip MRI in LCPD treatment decision-making processes between pediatric orthopedic surgeons and orthopedic surgery residents. MATERIAL AND METHODS Eight orthopedic surgery residents and eight pediatric orthopedic surgeons were invited to retrospectively evaluate hip radiography images and MRI sections of 34 patients with LCPD. The treatment choices were divided into two groups as conservative and surgical. Gwet's AC1 analysis was used to establish the relative level of intra-observer agreements. The correlation between the professional experience and the agreement parameters was also evaluated using the Pearson correlation coefficient. ANOVA was used to compare multiple groups. p ≤ 0.05 was statistically significant. RESULTS For both groups most preferred treatment method was conservative approaches based on plain radiography and MRI. The resident group showed a significant shift from conservative treatment to surgical treatment choices after MRI evaluation. The difference between the frequencies of each treatment choice for pediatric orthopedic surgeons was not statistically significant among different imaging modalities, but a comparison of the changes in surgical treatment revealed a significant difference between the imaging modalities, with a trend towards more complicated treatment choices. DISCUSSION Conservative methods were the most preferred treatment choice in the study, as it is common. It was observed that treatment choices changed when patients were evaluated together with MRI. Compared to plain radiographs, MRI provides sufficient and particular information for evaluating the structures of the hip joint components. CONCLUSIONS We found that consideration of MRI data in LCPD patients changed treatment recommendations substantially towards more complicated surgical procedures. We consider this to be an 'MRI effect' where using a more complex imaging modality leads surgeons to more complicated treatment modalities in LCPD. Key words: imagnetic resonance imaging, reliability, MRI effect, Perthes disease, children.

Hip Morphology in Early-stage LCPD: Is There an Argument for Anatomic-specific Containment?

BACKGROUND

Early containment surgery has become increasingly popular in Legg-Calvé-Perthes Disease (LCPD), especially for older children. These procedures treat the proximal femur, the acetabulum, or both, and most surgeons endorse the same surgical option regardless of an individual patient's anatomy. This "one-surgery-fits-all" approach fails to consider potential variations in baseline anatomy that may make one option more sensible than another. We sought to describe hip morphology in a large series of children with newly diagnosed LCPD, hypothesizing that variation in anatomy may support the concept of anatomic-specific containment.

METHODS

A retrospective review of a prospectively collected multicenter database was conducted for patients aged 6 to 11 at diagnosis. To assess anatomy before significant morphologic changes secondary to the disease itself, only patients in Waldenström stages IA/IB were included. Standard hip radiographic measurements including acetabular index, lateral center-edge angle, proximal femoral neck-shaft angle (NSA), articulotrochanteric quartiles, and extrusion index (EI) were made on printed anteroposterior pelvis radiographs. Age-specific percentiles were calculated for these measures using published norms. Significant outliers (≤10th/≥90th percentile) were reported where applicable.

RESULTS

A total of 168 patients with mean age at diagnosis of 8.0±1.3 years met inclusion criteria (81.5% male). Mean acetabular index for the entire cohort was 16.8±4.1 degrees; 58 hips (34.5%) were significantly dysplastic compared with normative data. Mean lateral center-edge angle was 15.9±5.2 degrees at diagnosis; 110 (65.5%) were ≤10th percentile indicating dysplasia (by this metric). Mean NSA overall was 136.5±7.0 degrees. Fifty-one (30.4%) and 20 (11.9%) hips were significantly varus (≤10th percentile) or valgus (≥90th percentile), respectively. Thirty-five hips (20.8%) were the third articulo-trochanteric quartiles or higher suggesting a higher-riding trochanter at baseline. Mean EI was 15.5%±9.0%, while 63 patients (37.5%) had an EI ≥20%.

CONCLUSIONS

The present study finds significant variation in baseline anatomy in children with early-stage LCPD, including a high prevalence of coexisting acetabular dysplasia as well as high/low NSAs. These variations suggest that the "one-surgery-fits-all" approach may lack specificity for a particular patient; a potentially wiser option may be an anatomic-specific containment operation (eg, acetabular-sided osteotomy for coexisting dysplasia, varus femoral osteotomy for valgus NSA).

LEVEL OF EVIDENCE

Level IV.

Medium-term outcomes of total hip arthroplasty in juvenile patients

BACKGROUND

Juvenile hip osteoarthritis is often the end result of congenital conditions or acquired hip ailments occurred during the paediatric age. This study evaluated the middle term results of total hip arthroplasty for end-stage juvenile hip osteoarthritis.

MATERIALS AND METHODS

This is a retrospective analysis of prospectively collected data on a cohort of 10 consecutive patients (12 hips), aged between 14 and 20 at operation, who underwent cementless total hip arthroplasty for end-stage juvenile secondary hip osteoarthritis in two orthopaedic tertiary referral centres between 2009 and 2018.

RESULTS

Juvenile hip osteoarthritis occurred as a consequence of developmental dysplasia of the hip, Legg-Calvé-Perthes disease, femoral head necrosis or slipped capital femoral epiphysis. All patients showed a significant improvement in Harris Hip Score (p < 0.01) at 3.3 years average follow-up (range 0.7-10.1 years).

CONCLUSION

The management of juvenile hip osteoarthritis following developmental dysplasia of the hip, Legg-Calvé-Perthes disease, femoral head necrosis or slipped capital femoral epiphysis is still challenging. Careful preoperative planning is essential to achieve good outcomes and improve the Harris Hip Score in these young patients. Total hip arthroplasty is a suitable option for end-stage secondary juvenile hip osteoarthritis, when proximal femoral osteotomies and conservative treatments fail to improve patients' symptoms and quality of life.

LEVEL OF EVIDENCE

IV.

Correlation between MRI and hip arthroscopy in children with Legg-Calve-Perthes disease

BACKGROUND

Most of the information available about Legg-Calve-Perthes disease (LCPD) at present is gained through imaging modalities including plain radiographs and magnetic resonance imaging (MRI). But the accuracy of MRI in this disease and its predictive value to reveal various intra-articular pathologies is not known. We correlated the findings of MRI with those seen on hip arthroscopy in children with active stage of LCPD.

METHODS

We conducted a prospective observational study in which MRI findings were correlated with corresponding findings on hip arthroscopy in a cohort of 25 patients of active LCPD below 12 years of age. The parameters noted on MRI included status of ligamentum teres, status of the labrum, synovial effusion if any, condition of the femoral and acetabular articular cartilage including chondral flaps, chondral indentation and intra-articular loose bodies. The indication of performing hip arthroscopy was persistent severe hip pain (Wong-Baker FACES pain scale ≥ 3) after 6 months of conservative management. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated for MRI considering arthroscopy as a gold standard.

RESULTS

Synovial effusion was seen in a large number of patients on both MRI (17) and hip arthroscopy (24). The sensitivity (95% confidence interval) of MRI was found to be low, especially with respect to labral tears [25% (0.63-80.6)] and intra-articular loose bodies [20% (0.51-71.6)]. NPV for synovial effusion was also found to be low [12.5% (0.32-52.7)], although specificity and PPV of MRI were found to be good for all the parameters.

CONCLUSIONS

MRI cannot be completely relied upon for identifying all the intra-articular pathologies in children with LCPD, although it has a good complimentary role. In patients with severe persistent pain with suspicion for joint changes, hip arthroscopy can provide a safe and efficient procedure (better than MRI) for eliciting the associated joint pathology.

Hip preservation surgery for adolescents and young adults with Post-Perthes Sequelae

BACKGROUND

Impingement ensures a narrow arc of pathologic loading in adolescent hips with sequelae of Perthes Disease. Proper surgical interference when the hip is still in the pre-arthritic stage restores function and protects the young hip from early degenerative changes.

METHODS

Osteochondroplasty at the femoral head-neck junction and relative lengthening of the femoral neck by distal transfer of the greater trochanter was performed for 12 adolescents with combined intra-articular/extra-articular impingement due to sequelae of Perthes disease in terms of coxa magna, coxa plana, coxa brevis, with an overriding greater trochanter. The safe surgical hip dislocation approach was performed in all cases. Patients were followed for an average of 24 months.

RESULTS

The Harris hip scores improved from an average of 58 preoperatively (range 50 to 69) to 94 postoperatively (range 91 to 97) at latest follow up. The range of hip flexion improved from a preoperative value of 84.2° (range, 60 to 105°) to value of 120.8° (range, 95 to 130°). Changes in hip flexion averaged 28.6° (range, 15 to 45°). Mean internal rotation increased to 26° ± 12°, and abduction to 38° ± 11°. Alpha angle improved to 40° ± 8°. The mean of center-trochanteric distance improved from an average of -18 mm to -1 mm. No osteonecrosis or chondrolysis was noted up to the time of the latest follow up.

CONCLUSION

Elimination of narrow arc of pathologic loading due to impingement is the main advantage of the proposed surgical technique. Other advantages include increased abductor lever arm and restoration of hip joint range of motion with normalization of the loading conditions, and hence future development of degenerative arthritis and the anticipated need for a future joint replacement surgery could be prevented or delayed. Femoral head vascularity is well maintained with the proven safety of the presented surgical approach.

Exploring the Association between Legg-Calvé-Perthes Disease and Attention Deficit Hyperactivity Disorder in Children

BACKGROUND

Legg-Calvé-Perthes disease (LCPD) is an idiopathic hip osteonecrosis prevalent in children < age 15 years. The etiology remains incompletely understood, partly because of multiple potential environmental risk factors and partly because of lack of genetic markers. It has been hypothesized that hyperactivity may induce mechanical stress and/or vascular damage at a fragile joint.

OBJECTIVES

To assess children with LCPD for markers of attention deficit hyperactivity disorder (ADHD) relative to their unaffected comparably aged siblings to exclude the contribution of hyperactive behavior versus environmental and/or genetic factors in LCPD.

METHODS

All children followed in the Pediatric Orthopedic Clinic, and their comparably aged siblings, were recruited. ADHD was assessed using the TOVA computerized test and DSM-IV criteria. Quality of life and sleep disorders as ancillary tests were assessed using the Child Health Questionnaire (Parent Form 50), Pediatric Outcomes Data Collection Instrument, and Pediatric Daytime Sleepiness Scale.

RESULTS

Sixteen children with LCPD (age 9.1 ± 3.3, 75% males) were compared with their closest-aged siblings (age 9.3 ± 2.6, 30% males). Mean TOVA scores of children with LCPD (-3.79 ± 2.6) and of their non-LCPD siblings (-3.6 ± 4.04) were lower relative to the general population (0 ± 1.8, P < 0.0001). Both group means were in the ADHD range (≤ -1.8) implying that 73% of this LCPD cohort and 53% of their non-LCPD siblings performed in the ADHD range, relative to 3.6% incidence expected in the general population (P < 0.0001). Other test results were similar in both groups.

CONCLUSIONS

Our findings in a small cohort of children with LCPD and their comparably aged siblings do not support an association between LCPD and ADHD. ADHD markers were equally high in the LCPD children and siblings.

Legg-Calvé-Perthes Disease

Legg-Calve-Perthes disease (LCPD) is the insidious onset of idiopathic avascular necrosis of the hip in the pediatric population. The disease encompasses a wide spectrum of pathology, from mild with no long-term sequelae to severe with permanent degenerative change of the hip joint. A pediatric patient with hip pathology may initially only present with knee or thigh pain, thus obligating the clinician to maintain awareness about the hip during examination. Common physical examination findings include deficits in hip abduction and internal rotation, along with Trendelenburg gait in late stages. Plain radiographs demonstrate changes in the anterolateral aspect of the femoral head, sometimes only seen on the frog lateral X-ray in early stages. Treatment options aim to restore range of motion and maintain adequate coverage of the femoral head. When appropriate, surgery is used to reorient the femoral head or pelvis to maintain coverage.

Transient synovitis, septic hip, and Legg-Calvé-Perthes disease: an approach to the correct diagnosis

Transient synovitis, septic hip, and Legg-Calvé-Perthes disease are common conditions in children. Distinguishing between these disorders can be a diagnostic challenge. Similar presentations, in an age group difficult to examine, coupled with literature that is confusing creates difficulty. It is important to make the correct diagnosis of septic hip in a timely fashion to avoid serious and potentially crippling consequences. As there is no single test for discriminating between these conditions, knowledge of the nuances of clinical presentation, physical examination, laboratory investigations, and imaging is essential. Judicious use of clinical algorithms can complement clinical acumen.

Tension band wiring for proximal femoral varus osteotomy fixation in children

For proximal varus osteotomy of the femur in children, a stable fixation, is a concern regarding the safety and the protection of the surgery. The methods of fixation are mostly represented by plating systems; however, the tension band wiring is a simple and eligible option for fixation of proximal femur osteotomy. The purpose of this retrospective case series study is to evaluate outcomes and bone remodelation after using the tension band wiring technique to fixate proximal femoral varus osteotomies in children.The study enrolled 20 patients who underwent femoral varus osteotomy to treat Legg-Calvé-Perthes disease and other causes of necrosis of the femoral head. The mean patient age at the time of surgery was 7.4 ± 2.3 years (range, 4.3-13.8 y), and the follow-up period averaged 10 ± 4.3 years (range, 4.7-20.8 y). To assess the effects of the osteotomy at the neck-shaft angle and its evolution over time, radiographs obtained preoperatively and during the follow-up were analyzed. The neck-shaft angle was measured independently by 2 observers, and intraclass correlation coefficients (ICCs) were assessed for reliability.The ICC analysis showed good reliability. There was a significant reduction in the neck-shaft angle (P < 0.001) between the preoperative and the immediate postoperative periods, with an estimated difference of 14.3°. Between the immediate and the early postoperative periods, the estimated difference was 2.1°, which indicated a significant increase in the neck-shaft angle (P = 0.003). Between the early postoperative period and the final evaluation, there was a significant increase (P < 0.001), with an estimated difference of 7.0°. No implant failures or other complications were observed, but 1 case of peri-implant femoral fracture occurred >17 years postsurgery.The tension band wiring technique proved to be a simple and effective method for fixating proximal femoral varus osteotomy in children.The level IV is appropriated for our study (case series, retrospective).

[Accuracy of proximal femur correction achieved with LCP paediatric hip plates]

PURPOSE OF THE STUDY

The aim of the study was to evaluate, in comparison with the pre-operative planning, the accuracy of proximal femur correction achieved with the use of locking compression paediatric hip plates (LCP) in children and adolescents and to assess pre- and post-operative complications.

MATERIAL AND METHODS

A group of 52 patients in whom proximal femoral osteotomy using the LCP was performed on a total of 55 hips between September 2009 and February 2013 were retrospectively evaluated. The following diagnoses were treated: unstable hip in cerebral palsy, 18 operations; Legg-Calvé-Perthes disease, 10 operations; coxa vara of aetiology other than coxa vara adolescentium (CVA), eight operations; true CVA, six operations; femoral shortening by the Wagner method, six procedures; proximal femoral derotation osteotomy, four procedures; and post-traumatic pseudoarthrosis of the proximal femur, three operations.

RESULTS

Compared with the pre-operative plan, the average deviation of the colodiaphyseal angle was 5.2° (1° to 11°) in 18 unstable hips; 4.7° (1° to 10°) in 10 cases of Legg-Calvé-Perthes disease; 4.5° (3° to 6°) in eight hips with coxa vara of aetiology other than CVA; 6.5° (2° to 13°) in six CVA hips; 4.5° (1° to 10°) in six cases of femoral shortening; 3.5° (1° to 5°) in four derotation osteotomies; and 3.7° (0° to 6°) in three corrections of pseudoarthrosis. In one patient, osteosynthesis failed due to screws being pulled out from the proximal fragment; re-osteosynthesis was carried out using a conventional angled blade plate.

DISCUSSION

As in other international studies, our results confirmed a high accuracy of proximal femur correction with use of the LCP instrumentation. The reported higher time requirement for this technique seems to be related to the learning curve and, with more frequent use, will probably be comparable to the time needed for application of conventional hip angled plates.

CONCLUSIONS

The up-to-date LCP fixation system using the principle of angular stability for correction of the proximal femur in children is a clear advancement and its higher costs are certain to be outweighed by its higher accuracy and thus better results.

[Radiologic correlation between the lateral pillar classification stages and the presence of femoroacetabular impingement in patients with Legg-Calvé-Perthes disease]

BACKGROUND

Lateral pillar classification has proven to be useful for the prognosis and treatment of patients with Legg-Calvé-Perthes disease. Most patients progress to skeletal maturity with some kind of morphologic alteration. Femoroacetabular impingement is a condition that results in early osteoarthrosis. The objective of this study was to determine whether there is a correlation between the initial lateral pillar classification and the presence of final femoroacetabular impingement.

MATERIAL AND METHODS

A retrospective review of 61 patients with Legg-Calvé-Perthes disease was conducted (68 hips); they were classified into three groups according to the lateral pillar classification. At the time of skeletal maturity the radiographic presence of femoroacetabular impingement was determined and the correlation between both variables was analyzed.

RESULTS

The use of the lateral pillar classification resulted in seven hips considered as type A, 37 as type B, and 24 as type C. Three of the type A hips had radiographic findings of cam femoroacetabular impingement, three of pincer femoroacetabular impingement, and one of mixed femoroacetabular impingement. Among type B hips, radiographic data of cam femorocetabular impingement were found in17, of pincer femoroacetabular impingement in 12, and of mixed femoroacetabular impingement in 10. Twenty-three of the type C hips had radiographic data of cam femoroacetabular impingement, 15 of pincer femoroacetabular impingement, and 15 of mixed femoroacetabular impingement.

CONCLUSION

Patients with Legg-Calvé-Perthes disease have a directly proportional relationship between the initial lateral pillar classification and subsequent femoroacetabular impingement.

Chronic expanding hematoma might be a potential insidious challenge for orthopedic surgeon

Chronic expanding hematomas can cause alarm both to the physician and to the patient because they simulate the growth of a malignant tumor. It is not always possible to bring back the cause to a specific traumatic event that the patient can remember. At this purpose, it is important to have a precise diagnosis when dealing with a growing mass and to exclude any malignancy before processing any treatment. In this article, we report the case of a young patient admitted to our department with a suspected soft tissue sarcoma, but imaging study and histological examination revealed to be hematoma. The authors want to emphasize the necessity of performing a complete clinical and instrumental study when surgeon has to deal with a growing mass. From accurate analysis of imaging, it is often possible to discriminate between malignancy and other benign forms.

Pathological gait in children with Legg-Calvé-Perthes disease and proposal for gait modification to decrease the hip joint loading

PURPOSE

Legg-Calvé-Perthes disease (LCP) severely limits the range of hip motion and hinders a normal gait. Loading of the hip joint is a major consideration in LCP treatment. The aim of this study was to evaluate gait patterns in LCP and identify gait modifications to decrease the load on the affected hip.

METHODS

Forty children with unilateral LCP were divided into three groups based on the time base integral of the hip abductor moments during single stance on the affected side acquired during instrumented 3D gait analysis. X-rays of the affected hip were classified according to Herring and Catterall.

RESULTS

Children in the "unloading" group spontaneously adopted a Duchenne-like gait with pelvis elevation, hip abduction and external rotation during single support phase. The "normal-loading" group showed pelvis elevation with a neutral hip position in the frontal plane. In the "overloading" group the pelvis dropped to the swinging limb at the beginning of stance accompanied by prolonged hip adduction. The time base integral of the hip abductor moments during single stance correlated positively with the X-ray classifications of Herring and Catterall, hip abduction angle and age. Older children preferred to walk in hip adduction during single stance, had more impaired hips and tended to overload them.

CONCLUSION

The hip overloading pattern should be avoided in children with LCP. Gait training to unload the hip might become an integral component of conservative treatment in children with LCP.

Current concepts in the diagnosis and management of femoroacetabular impingement

Femoroacetabular impingement is becoming increasingly recognised as a cause of hip pain in the young adult. It is thought that the condition may lead to acetabular labral tears, chondro-labral separation, chondral delamination and eventually predispose to osteoarthritis of the hip. Efforts have thus been directed to diagnosing and treating the underlying pathology and subsequent sequelae. This article presents the relevant literature with regards to the aetiology of femoroacetabular impingement, its clinical features, investigations and options of management. Finally outcomes relating to both open and arthroscopic approaches to treatment are discussed.

Treatment options for symptomatic degenerative joint disease secondary to Legg-Calvé-Perthes disease

The treatment options for neglected Legg-Calvé-Perthes disease (LCPD) leading to symptomatic degenerative joint disease always have posed a challenge for the orthopedic surgeon. In addition, the literature is disorganized in this regard. Therefore, a structured literature review of the treatment options for the symptomatic sequelae of LCPD, especially in the context of joint replacement and resurfacing, is very much needed.

Comparison of bone age delay and recovery in Meyer dysplasia and Legg-Calvé-Perthes disease: a pilot study

BACKGROUND

Meyer dysplasia (MD) is a rare disease but readily mistaken for Legg-Calvé-Perthes disease (LCPD). Although most published studies on MD have characterized and differentiated it from LCPD radiologically and clinically, differences with regard to bone age delay and recovery have not been sought. We deemed it necessary to distinguish bone age delay and recovery patterns between the two entities for better differentiation, prognostication, and parental advice.

METHODS

Bone age delay and recovery of eight patients who were initially diagnosed with LCPD but were found to have MD were retrospectively reviewed and compared with those of age-matched patients with LCPD. Based on hand radiographs, the radius-ulna-short bones (RUSs) and carpal bone ages were determined using the Tanner and Whitehouse 3 (TW3) method. Minimum follow-up was 2 years (range 2-5 years). Differences in RUS and carpal bone ages and recovery patterns between the two entities were analyzed using trend lines in scatter plots.

RESULTS

The mean delay of RUS bone age was significantly less in MD (0.52 ± 0.87 years) than in LCPD (1.11 ± 0.99 years). However, the difference between the mean carpal bone age delay in MD (1.13 ± 1.28 years) and LCPD (1.47 ± 1.19 years) was not significant. Trend lines showed faster bone age recovery patterns in MD than in LCPD.

CONCLUSIONS

Bone age was delayed in both MD and LCPD but was less delayed in the former. RUS bone age showed more significant differences than carpal bone age when comparing the two entities and hence might be more useful for differentiating the two. Earlier bone age recovery patterns may be anticipated in patients with MD.

Clinical presentation of young adults after Legg-Calvé-Perthes disease

The purpose of the present study was to review the clinical and radiological outcome of young adult individuals who had Legg-Calvé-Perthes disease (LCPD) during child age. After a mean follow-up of 18.7 +/- 6.2 years, 25 young adults with various morphological deformity grades were assessed clinically and radiologically. Deterioration of hip joint function and onset of pain were found to manifest early in the intermediate follow-up of LCPD and to correlate with the residual hip deformity.

Systemic effects of zoledronic acid in children with traumatic femoral head avascular necrosis and Legg-Calve-Perthes disease

BACKGROUND

Intravenous bisphosphonate therapy is associated with preservation of femoral head sphericity and congruence in 77% of children with traumatic avascular necrosis. The aim was to describe the systemic effects of intravenous zoledronic acid (ZA) on bone and mineral metabolism in otherwise normal children and adolescents with femoral head AVN.

MATERIAL AND METHODS

37 children (age 10.8+/-2.76 years) diagnosed with avascular necrosis AVN (Slipped Capital Femoral Epiphysis (SCFE), N=20 or Legg-Calve-Perthes disease (LCPD), N=17) were treated with at least 12 months of ZA. Bone mineral density (BMD) by DXA, bone morphometry and mineral homeostasis were evaluated at baseline, 6, 12 and 18 months. Data was retrieved retrospectively.

RESULTS

All children maintained height SD during treatment. BMI SD increased in the SCFE subgroup during the first 12 month period. Bone age increased appropriately. Age adjusted total body BMD, lumbar spine BMD and lean tissue mass adjusted bone mineral content (BMC) Z-scores increased significantly over the 18 months of treatment. The LS.BMD increase was greater in LCPD than in SCFE leading to more individuals with LCPD having a LS.BMD((age))Z-score over 2 SD at 12 months follow-up. Biochemical markers of bone turnover were decreased and PTH increased during the first 12 months of treatment and bone modeling was reduced. All markers stabilised over the next 6 months. There were no incidences of fracture, spondylolisthesis or osteonecrosis of the jaw.

CONCLUSION

We here report that ZA in otherwise healthy children with femoral head AVN increases BMD - most pronounced in the LCPD group - and reduces bone modeling and turnover. Further efficacy and safety data are required before this therapy can be widely recommended.

Resurfacing for Perthes disease: an alternative to standard hip arthroplasty

Metal-on-metal total hip resurfacing is an alternative to conventional total hip arthroplasty with several reports describing the benefits of this procedure in young patients. We retrospectively compared the clinical (including range-of-motion and leg length restoration) and radiographic outcome of resurfacing in young patients with Legg-Calvé-Perthes to those of patients of a similar age treated with a standard total hip arthroplasty. Eighteen patients (19 hip resurfacings) who had a mean age of 33 years (range, 18-34 years) were followed for a minimum of 26 months (mean, 51 months; range, 26-72 months). We used an anterolateral approach in four hips and a posterior approach with a trochanteric advancement in 15 hips. Eighteen of the 19 hips had Harris hip scores greater than 80 points at final followup. All patients improved range of motion while avoiding any clinically apparent impingement. Leg length was gained in 16 hips where preoperative measurements were available. The short-term results of hip resurfacing for the treatment of Perthes disease compare similarly to those found in the literature for standard total hip arthroplasty in young patients. The trochanteric advancement technique described may aid in treating the deformed femoral anatomy.

Evaluation of radial-sequence imaging in detecting acetabular labral tears at hip MR arthrography

OBJECTIVE

In recent years, radial imaging has been advocated for improved visualization of the acetabular labrum in magnetic resonance arthrography of the hip. The purpose of this study was to investigate whether radial imaging demonstrates labral tears not visible on standard imaging planes.

METHODS

Fifty-four consecutive magnetic resonance (MR) arthrograms of the hip that included radial imaging over 2 years were retrospectively analyzed by two radiologists. Standard imaging planes and radial imaging were reviewed for identification of labral tears in four specific areas of the labrum: anterosuperior, posterosuperior, anteroinferior, and posteroinferior. The standard imaging sequences include fat-saturated spin-echo T1-weighted images in the coronal and oblique axial planes, non-fat-saturated T1-weighted images in the coronal and sagittal planes, and T2-weighted sequence in the axial plane. Radial imaging was performed as previously described using fat-saturated T1-weighted sequences.

RESULTS

Using standard imaging planes, 50 anterosuperior, 31 posterosuperior, 10 anteroinferior, and 9 posteroinferior labral tears were detected in 54 MR arthrograms of the hip. Using radial sequences alone, 44 anterosuperior, 25 posterosuperior, 9 anteroinferior, and 5 posteroinferior labral tears were detected. In all four areas of the labrum, the radial imaging did not show any labral tear not seen on standard imaging planes.

DISCUSSION

In MR arthrography of the hip, radial imaging did not reveal any additional labral tears. Standard imaging planes sufficiently demonstrate all acetabular labral tears.

[Focal osteochondral necrosis of the femoral head of an adult after Legg-Calve-Perthes disease in childhood]

In the treatment of circumscribed osteochondral lesions of the knee and the ankle joint autologous osteochondral transplantation (AOT) has been established as one of the possible operative therapies. However, there is less experience with the use of AOT on other joints (shoulder, elbow). The care of osteochondral defects of the hip joint with autologous osteochondral transplantation can still be regarded as an absolute rarity. Facing a focal osteochondral necrosis in a young female adult after LCP disease in childhood, we report about an autologous osteochondral transplantation at the femoral head using the diamond bone cutting system.

[The limping child with a painful hip]

Hip pain is a frequent cause for limping in children. Etiology work out is oriented by the age of the child, the existence of a traumatic or infectious background, the child's morphology and ethnic origin, and most of the diagnoses will require only a standard X-ray and an ultrasound to be confirmed. In this way, the three main causes to be considered in children of less than 10 years of age are septic arthritis, transient synovitis and Perthes disease. Septic arthritis will require an urgent treatment, whereas Perthes disease will need a long care and follow up in order to watch for a poor outcome that will necessitate a surgical treatment to restore containment of the femoral head. In the adolescent, especially in case of overweight, the first etiology to be considered is slipped femoral capital epiphysis, a condition that requires an early and adequate surgical treatment (in situ screw fixation), in order to avoid further displacement and femoral head deformity of poor prognosis.

[The prognostic factors in perthes disease]

The purpose of this study was to evaluate the role of selected factors which may play role in the estimation of late result during Perthes disease and which one can be eliminated during treatment period. The study population consisted of 311 patients (50 patients with bilateral disease, 361 hips joint) who had reached skeletal maturity at last follow up. All hips were treated by containment methods (bed rest and traction in abduction, Petri cast, brace, varus osteotomy, Salter osteotomy and shelf acetabuloplasty). Both clinical and radiological parameters (taken during fragmentation stage) were included in our study: gender, age at the onset, hip joint abduction, type of treatment, extend of the femoral head necrosis according to the Herring and Catterall classification, LLD, premature growth plate arrest, ATD and ATD index, lateral acetabulum shape - type I - normal, concave lateral acetabulum margin, type II--flat, horizontal and type III--convex, sloping, femoral head subluxation, femoral head sphericity disturbance according to the Mose, risk factors according to the Catterall, Wiberg angle, Eyre-Brook index. Long-term results were evaluated according to the Stulberg classification and were divided into two groups: good result--Stulberg group 1 or 2 and poor and bad result--Stulberg group 3, 4 or 5. The unilateral and bilateral Perthes disease was estimated separately. The statistical analysis revealed in unilateral Perthes disease that next risk factors may lead to poor or bad late result: age at the onset 9 and more years, group 3 or 4 according to Catterall and group C according to Herring classification, type III lateral acetabulum shape, hip joint abduction less than 10 degrees, premature growth plate arrest, ATD index less than 0.8, femoral head subluxation more than 20%, femoral head sphericity disturbance more than 5mm, Gage sign, calcification laterally to the femoral head (sensitivity 85.0%, specificity 98.7%). Bilateral Perthes disease: age at the onset over 6 years, group 3 or 4 according to Catterall and group C according to Herring classification, hip joint abduction less than 10 degrees and calcification laterally to the femoral head (sensitivity 81.8%, specificity 92.3%). The statistical analysis showed which clinical and radiological factors may play an important role in estimation of late results during Perthes disease. Additionally during fragmentation stage of Perthes disease we have possibility to correct or eliminate some of the risk factors - femoral head subluxation, lateral acetabulum shape and hip joint abduction and improve the late result.

Leg length discrepancy in Legg-Calve-Perthes disease

The purpose of this study was to determine the incidence of the leg length discrepancy (LLD) in Legg-Calve-Perthes disease and whether there is any correlation between LLD and age at onset, gender, type of treatment, and severity of disease. The study population consisted of 261 patients with unilateral involvement who had reached skeletal maturity at last follow-up. All hips were treated by containment methods (bed rest and traction in abduction, Petri cast, brace, varus osteotomy, Salter osteotomy, and shelf acetabuloplasty). The late results were classified according to the Stulberg classification. LLD was found in 33 patients and ranged from 1 to 5.2 cm (average 2.51 cm). The limb shortening was observed in Herring group B (average 2.18 cm) and C (average 2.82 cm) and was statistically significant more common in group C. The statistical analysis revealed no statistical difference between the age at onset, sex, and type of treatment with regard to LLD; nevertheless, patients in Herring group C with LLD were younger than patients in group B, and LLD was seen more often after varus osteotomy. The amount of residual shortening of the affected limb in Legg-Calve-Perthes disease at the end of skeletal growth seems to depend on the extent of involvement and the presence of a growth arrest. A varus osteotomy produces more significant shortening than other methods of treatments. The age at the onset of symptoms and sex do not influence the amount of LLD, but early onset of the disease can result in more severe limb shortening.

Residual shortening after Legg-Calve-Perthes disease, focusing on the response of the ipsilateral tibia

Residual shortening of the affected limb was measured at skeletal maturity by teleoroentgenograms in 68 patients with Legg-Calve-Perthes disease (LCPD); special attention was paid to the length of the ipsilateral tibia. Of these 68 patients, 38 were treated by abduction orthosis (AO) and 30 by femoral varus osteotomy (FVO). Residual shortening in AO group was significantly greater than that in FVO group. The femoral lengths in both of these groups were similar (12.5 mm in the AO group and 10.1 mm in the FVO group), but the tibial lengths were significantly different (2.5 mm shortening in the AO group and 0.9 mm lengthening in the FVO group). Residual shortening in the patients treated by FVO was less than that in patients treated by AO. The difference is speculated to be caused by the overgrowth of the ipsilateral tibia.

Developmental pattern of femoral shortening following devascularization of the capital femoral epiphysis in piglets

To investigate the developmental pattern of femoral shortening in Legg-Calve-Perthes disease, the authors made an experimental model of the disease in piglets by devascularizing the capital femoral epiphysis and following the piglets to skeletal maturity. The discrepancy first increased in the postoperative 0 to 8 weeks (1.2-1.9 mm of shortening per week), then decelerated for a considerable period during the postoperative 8 to 16 weeks (0.2-0.6 mm per week), and then increased again toward the end of the growth period of the postoperative 20 weeks (1.2 mm per week). The developmental pattern of femoral shortening showed an upward slope/plateau/upward slope pattern, as in type IV of the Shapiro classification. As the mechanism of the observed pattern, the authors presumed reduced epiphyseal height and growth retardation in the physis during the initial upward slope, a repair process at the plateau phase, and premature physeal closure during the second upward slope.

The correlation between coxa magna and final outcome in Legg-Calve-Perthes disease

This study evaluated the final outcome of coxa magna that developed as a sequela of Legg-Calve-Perthes disease. The final outcomes at skeletal maturity were assessed by the Stulberg classification in 85 children with unilateral Perthes disease. Among them, 21 children had a bilateral arthrogram at the active stage of the disease, and the arthrogram measurements were compared with those measured at disease healing and at skeletal maturity. Coxa magna was observed in 53% (45/85), with a mean increase in 20.0 +/- 7.2%. These coxa magna and resulting acetabular deformities occurred in the early stage of the disease. In 68 hips with mild (1-9% increase) or moderate (10-19%) coxa magna, the final results were Stulberg I or II in 57 hips and III in 11. In 17 hips with severe coxa magna (> or =20%), the results were I or II in one hip, III in nine, and IV in seven. This means that 41% of the hips with severe coxa magna might have osteoarthritis later in life.

Surface arthroplasty in young patients with hip arthritis secondary to childhood disorders

Legg-Calvé-Perthes disease (LCP) and slipped capital femoral epiphysis (SCFE) may result in alterations of the proximal femoral morphology, leading to the development of hip osteoarthritis as a young adult. Hip surface arthroplasty presents special technical challenges in these patients because of the abnormal anatomy of the head and neck. The authors reviewed the radiographic and clinical results of patients with a history of LCP or SCFE who underwent hip resurfacing between 1996 and 2002. Despite the challenges in performing hip resurfacing in this patient population and the inability to completely normalize hip anatomy, biomechanics, and leg length discrepancy, the results to date have been encouraging.

Urine glycosaminoglycans in children with transient hip synovitis and Perthes disease

Urine glycosaminoglycan concentrations were measured in 24-h urine samples collected from ninety children (30 children with Perthes disease, 30 with transient synovitis and 30 control participants). Significantly decreased levels of urine glycosaminoglycans were found in Perthes disease patients compared with those with transient synovitis and the control group.

Legg-Calvé-Perthes disease in a rhesus macaque (Macaca mulatta)

A juvenile rhesus macaque presented with atrophy of the musculature of its left leg. Physical examination localized the problem to the coxofemoral joint. Radiography revealed changes consistent with Legg-Calvé-Perthes (LCP) disease. Femoral head ostectomy was performed, and the femoral head was submitted for histologic examination, results of which confirmed a diagnosis of LCP.

A case of intra-articular snapping hip caused by articular cartilage detachment from the deformed femoral head consequent to Perthes disease

We treated a relatively rare case of intra-articular snapping hip caused by an articular cartilage fragment detached from the deformed femoral head consequent to Perthes disease. We report the pathology as well as diagnosis and treatment of this case. A 24-year-old man presented with right coxalgia. He was diagnosed with Perthes disease at a young age and was treated conservatively. Six months before the patient visited our department, he started having intense pain accompanied by a clicking sound when he extended and at the same time externally rotated the right hip joint from a flexed position. Although a radiogram showed Stulberg class 3 deformity of the femoral head, the joint space was well preserved and no bone cyst or bone spur formation was seen. Computed tomography (CT) and magnetic resonance imaging (MRI) showed no abnormal findings inside the femoral head and in the hip joint. However, when 5 mL of 2% lidocaine hydrochloride was injected into the hip joint, the snapping phenomenon persisted but the sharp pain was temporarily resolved. Arthroscopic finding showed a valve-shaped detachment of articular cartilage in the anteromedial side of the femoral head. Arthroscopic shaving of the detached fragment was conducted. The pain and clicking sound accompanying hip joint movement disappeared postoperatively. Hip joint arthroscopy is useful for the diagnosis and treatment of intra-articular type snapping hip when the cause of snapping is inside the joint cavity.

The most severe forms of Perthes' disease associated with the homozygous Factor V Leiden mutation

It has recently been postulated that thrombophilia may have a role in the aetiology of Perthes' disease. The published reports, however, remain conflicting. In this study a retrospective analysis of the coagulation parameters was made in 47 patients with Perthes' disease and the results compared with the clinical data. Five patients with Factor V Leiden mutation were found (10.6%) and surprisingly four of them had a homozygous pattern. These four patients showed the most severe form of the disease, Catterall group IV, with flattening of the entire epiphysis, involvement of the metaphysis, shortening and broadening of the femoral neck, trochanteric overgrowth and developed mushroom-shaped aspherical laterally displaced femoral heads in dysplastic acetabula. We would like to suggest that the homozygous form of Factor V Leiden mutation has some role in the clinical course of Perthes' disease and particularly its most severe form.

Intertrochanteric osteotomy in young adults for sequelae of Legg-Calvé-Perthes' disease--a long term follow-up

Between 1974 and 1999 we performed 15 intertrochanteric osteotomies in 14 patients with a painful hip secondary to Legg-Calvé-Perthes' disease. In seven patients, the osteotomy was combined with advancement of the greater trochanter, acetabular roof plasty, or both. One patient died 5 years after the osteotomy and one patient was lost to follow-up. One patient had a revision osteotomy 21 years after the initial osteotomy, and five patients had a prosthetic replacement 8-25 years after the osteotomy. The average follow-up of the remaining osteotomies was 11.3 years. An intertrochanteric osteotomy can decrease pain and improve clinical function medium and long term without radiological progression of joint degeneration.

[Congenital disorders of hemostasis in children with Perthes disease]

The level of selected parameters of the coagulation system and fibrynolysis (prothrombin time, partial thromboplastin time, fibrinogen level, albumin C system, V Leiden factor and III antithrombin level) in 25 children who had been treated with Perthes disease was evaluated. In three children prolonged prothrombin time occurred; in one child anomalous protein C system was noted. The remaining parameters were normal in all children. The investigation results reveal that congenital disturbances of the haemostasis system were not the cause of Perthes disease in 24 children.

[Premature femoral head growth plate closure in Perthes' disease]

The study population consisted of 311 patients (50 female and 261 male) who had reached skeletal maturity at last follow up (361 hips). The mean age at the onset of symptoms was 6 years and 10 months (range: 2.5-13 years). All patients were treated by containment methods (bed rest and traction in abduction, brace, Petri cast, varus osteotomy, Salter osteotomy and shelf operation). Premature growth plate closure was estimated according to Bowen (central and lateral). Necrosis of the femoral head was classified according to Herring and Catterall, late results according to Stulberg and Mose and leg length discrepancy on scanograms. Article-trochanter distance (ATD) was estimated according to the Edgren methods. Premature femoral head growth plate closure was found in 61 hips (central--41 and lateral--20). Statistical analysis did not reveal any correlation between the gender and type of treatment and premature growth plate closure. The central pattern of growth plate closure was more often seen to 6 years of age at the onset and the lateral over 9 years of age at the onset (p = 0.0176). Premature growth plate closure was observed more often in Herring group C and Catterall group 4 (p = 0.0001). Disturbances in femoral head sphericity according to Mose increased (except with bilateral Perthes' disease) and ATD decreased in patients with premature growth plate closure. Also premature growth plate closure increased the leg length discrepancy in Perthes' disease. Thirty two (52.5%) hips with abnormal physeal growth were classified into type I or II according to Stulberg classification, 16 (26.2%) into type III and 13 (21.3%) into type IV or V. Premature growth plate closure in Perthes' disease is more common in huge necrosis of the femoral head. The central pattern of growth plate closure is more often in younger children (to 6 years of age) and the lateral in older (over 9 years of age). With abnormal physeal growth the greater trochanter overgrow and ATD decreased, the leg length discrepancy and disturbances in sphericity of the femoral head increased. Premature growth plate closure increased satisfactory and poor results according to Stulberg classification.

Computed tomographic findings of osteochondritis dissecans following Legg-Calvé-Perthes disease

Routine radiographs in the follow-up study of Legg-Calvé-Perthes disease patient have generally been plain radiographs of the anteroposterior and frog-leg lateral view. Recently, several reports have found that osteochondritis dissecans can develop in 2% to 4% of Legg-Calvé-Perthes disease patients. Early roentgenographic recognition of this lesion is very important for its long-term prognosis. However, follow-up examination of the lesion using plain radiography is sometimes not satisfactory in terms of delineating the lesion. Accordingly, the authors performed computed tomography and three-dimensional reconstruction in 13 hips with osteochondritis dissecans following Legg-Calvé-Perthes disease and were able to obtain more precise information on the extent of the involvement, the degree of healing, the stability of the osteochondral fragment, and the location of the dislocated loose body.

Teardrop-femoral head distance after shelf acetabuloplasty for Perthes' disease

Shelf acetabuloplasty is an accepted treatment for Perthes' disease. Favourable outcomes have been reported. This study aimed at determining whether changes in femoral head subluxation after shelf acetabuloplasty occur and whether they predict outcome. We assumed that reduction of subluxation after shelf acetabuloplasty would improve the long-term outcome. During follow-up, growth presented as a source of error when comparing the amount of absolute subluxation. Correction for growth was achieved by calculating a subluxation index. This index showed a significant reduction during follow-up. There was no correlation between clinical and radiological outcome, but the fact that the subluxation index showed a decreasing trend could be promising regarding outcome. This might be one of the reasons why shelf acetabuloplasty produces its effect. Following shelf acetabuloplasty the enlarged acetabulum could possibly direct the growth of the femoral head to a better-contained joint. This could result in better joint congruity and lesser tendency to degenerative arthritis.