Comparison of outcomes of Salter and Varus osteotomies in the treatment of Legg-Calve-Perthes Disease: a retrospective cohort study.

Background Perthes disease is a rare childhood condition that affects the hip. It occurs when the blood supply to the rounded head of femur is temporarily disrupted. Without an adequate blood supply, the bone cells die, a process called avascular necrosis. There is limited data about surgical options in treatment of Perthes disease. The authors conducted this systematic review and meta-analysis to compare between femoral versus acetabular containment in the management of Perthes disease in terms of efficacy and complications, however there is a debate about the ideal way of treatment in Perthes disease. Objective To compare between femoral varus and acetabular containment osteotomies in children with Perthes disease, regarding the efficacy, long-term outcomes and complications. Methods This systematic review and meta-analysis examined studies that compared FVO and Pelvic Osteotomy. The authors searched the Medline database via PubMed, EMBASE, and Cochrane Library for studies published between 2012 and 2022. Results A total of 1051 patients were analyzed for different procedures, including 429 patients in the pelvic arm, 459 patients in FVO arm, and 163 patients in the combined arm. The number of hips included in the current analysis was 1069 hips, including 437 in pelvic arm, 469 in FVO arm, and 163 in the combined arm. The mean age for the included patients was 9.5±7.74 years, with 859 (81.8%) males and 192 (18.2%) females. There was an apparent predominance in males vs. females in all arms. The mean follow-up of the included studies was 8.6±8.32 years. We compared between the three procedures clinically, radiographic and complications. (FVO: Femoral varus osteotomy). Conclusion Femoral varus osteotomy and Pelvic osteotomy have shown comparable clinical and radiological improvement in treatment of perthes disease. The FVO group has shown higher rate than pelvic or combined osteotomies regarding post-operative arthritis and decrease range of motion. The pelvic group has shown higher rate than FVO and combined osteotomies regarding post-operative impingement and leg length discrepancy. There was no significant difference between the pelvic, femoral and combined osteotomies regarding range of motion, Trendelenberg, limping, post-operative pain and secondary knee deformity. In summary, this review provides evidence that femoral and pelvic osteotomies are safe, effective methods in treatment.

Computerized gait analysis in Legg Calvé Perthes disease—Analysis of the frontal plane

This is a retrospective observational study. Greater trochanteric epiphysiodesis (GTE) has been recommended to prevent Trendelenburg gait and limitation of the hip joint motion due to trochanteric overgrowth after femoral varus osteotomy (FVO) in Legg–Calvé–Perthes disease (LCPD). However, capital femoral physeal arrest frequently occurs in patients with severe disease (lateral pillar C), so GTE might not be as effective in these patients. The aim of this study was to compare trochanteric growth inhibition due to GTE after FVO between 2 age groups (<8 or >8 years) in patients with lateral pillar B and B/C border LCPD and evaluate the effectiveness of GTE compared with the normal, unaffected hip.This study included 19 children with lateral pillar B and B/C border LCPD in 1 leg who underwent FVO followed by GTE. Of the 19 children, 9 underwent GTE before the age of 8 years and 10 underwent GTE after 8 years of age. On radiographs taken at the immediate postoperative period and at skeletal maturity, the articulo-trochanteric distance (ATD), center-trochanteric distance (CTD), and neck-shaft angle (NSA) were compared between the 2 age groups. The amount of correction was compared between groups. The contralateral, unaffected hip was used as a control for trochanteric growth. The patients were clinically evaluated with Iowa hip score at the final follow-up.There was no significant difference between the 2 age groups in terms of time to GTE, length of follow-up, or lateral pillar classification. In the affected hip, the amount of correction of the ATD, CTD, and NSA was significantly greater in patients < 8 years than in patients > 8 years. However, in the unaffected hip, the change in the ATD, CTD, and NSA did not differ significantly between the 2 groups.We suggest that FVO followed by GTE for lateral pillar B and B/C border LCPD in patients under the age of 8 years can affect growth of the greater trochanter. However, effective growth inhibition due to GTE was not achieved after 8 years of age.

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

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).

This study compared the 5-year outcomes of isolated proximal femoral varus osteotomy (FO) and combined proximal femoral varus and pelvic osteotomy (FPO) for the treatment of hip displacement in children with cerebral palsy (CP) in Sweden, focusing on the number of reoperations and residual hip displacement. The study included 163 children with a 5-year follow-up after FO or FPO in the national Swedish CP surveillance program, CPUP. Descriptive statistics and univariate and multivariate Cox regression analyses were used to identify whether the age at surgery, sex, Gross Motor Function Classification System level, CP dominant symptom, hip migration percentage (MP), type of surgery (unilateral/bilateral), and history of soft tissue hip surgery were related to the 5-year outcomes after surgery. Failure after hip surgery was defined as a skeletal reoperation involving the hip and/or MP >50%. During the period 2001 to 2017, 163 children (65 girls) underwent 246 femoral and/or pelvic osteotomies (154 FO, 47 bilaterally; 92 FPO, 16 bilaterally) and had a 5-year follow-up; 95 and 74 children had ≥1 FO or FPO as the primary skeletal surgery, respectively. The mean preoperative MP (51%±18% for FO and 59%±17% for FPO, P =0.001) and age at surgery (6.2±2.5 years for FO and 7.3±2.8 years for FPO, P =0.014) differed between procedures. At the 5-year follow-up, 5 hips (5%) had reoperations and 5 hips (5%) had radiological failure among the 92 FPOs, and 33 (21%) had reoperations and 14 (9%) radiological failure among the 154 FOs. The difference in outcome failure rate was significant ( P <0.001). Multivariate Cox regression analysis showed a lower risk for failure with FPO [hazard ratio (HR)=0.32, 95% CI: 0.15-0.68] compared with FO. A higher preoperative MP increased the risk for outcome failure (HR=1.21, 95% CI: 1.15-1.36 for each 5% increment). FPO had a higher mean preoperative MP but a lower 5-year outcome failure rate compared with FO. A higher preoperative MP was associated with an increased risk of failure. Level II-prospective comparative study.

Background:Legg-Calve´-Perthes disease (LCPD) is an idiopathic avascular necrosis of the femoral head. There are multiple approaches to the treatment of LCPD ranging from conservative management to a wide variety of surgical methods. Conservative management necessitates extreme degrees of abduction in an orthosis for a longer period of time which further jeopardize capital femoral head vascularity. Surgical containment methods are used in cases where it is desirable. Initial surgical containment methods are varus or varus-derotational osteotomy of the proximal femur or an innominate osteotomy as described by Salter and other pelvic osteotomies. The purpose of this study was to describe the early results of containment methods by one-stage combined osteotomy (femoral varus osteotomy and Salter innominate osteotomy) in patients with severe LCPD.Materials and Methods:23 children were operated in the age group of 4–9 years for LCPD by one-stage combined osteotomy procedure between January 2005 and June 2012. There were 19 boys and 4 girls, left hip involved in 10 cases and right in 13 cases. Preoperatively, they were classified according to Catterall, Joseph's stage and lateral pillar (LP) classification. Postoperatively, clinical results were evaluated in accordance with Ratliff classification and radiological assessment was made by Mose's index, modified Stulberg classification and Epiphyseal extrusion index.Results:Seventeen hips were Catterall group III, 6 in group IV and all had two or more “head-at-risk” signs. There were 2 patients with stage IIA, 15 were in stage IIB and 6 were in stage IIIA as classified by Joseph's stage of disease. According to LP classification, 11 patients were group B, 3 were group B/C and 9 were in group C. At an average followup of 5.4 years (range 2–9.5 years), the clinical results were good in 12, fair in 9 and poor in 2. According to Mose scale, 8 patients had good results, 13 fair results and 2 had poor results. Based on modified Stulberg classification, there were 10 patients in group A, 11 in group B and 2 in group C. The average preoperative extrusion index was 23.6% which improved postoperatively to 9.5% at latest followup.Conclusions:The surgical treatment of LCPD with the best expected outcome is still a challenge. Advanced containment methods by one-stage combined osteotomy can be considered as an alternative treatment where femoral head subluxation or deformity which makes containment difficult or impossible by more conventional methods.

This is a retrospective review of 144 hips in 99 patients treated with femoral varus osteotomy between 1975 and 1995. Average follow-up was 5 years (range, 2-15 years). The majority of patients (67%) were nonambulatory spastic quadriparetics. The average age at the time of surgery was 7.7 years (range, 3-15 years). Radiographic parameters analyzed were the neck-shaft and center-edge (CE) angles and Reimer's migration index (MI). Results were considered good if the CE angle was >20 degrees and the MI <30%, fair if the CE angle was 0 degrees - 20 degrees and the MI 30-50%, and poor if the patient had persistent pain, a CE angle of <0 degrees , or an MI >50%. Twelve hips (8%) remained painful at final follow-up, and 12 hips (8%) dislocated despite surgery. Previous surgery, unilateral surgery, performing a pelvic osteotomy, and age at the time of surgery had no statistical influence on outcome. Good results were obtained in 43.1%, fair in 41.5%, and poor in 15.4%. Only the quality of the reduction obtained at surgery, judged by the increase in CE angle and the reduction in MI, had a statistical influence on final result. Athetoid patients fared as well as those with spasticity. Femoral varus osteotomy was effective in providing a stable pain-free hip in 84% of patients.

Upper femoral varus osteotomy of the proximal femur without rotation has been the surgical treatment of choice by the senior author (D.S.W.) in 124 cases of Legg-Calve-Perthes disease. There have been no previous studies documenting the nature of the remodeling process after this surgical procedure. The authors analyzed the radiographic changes that occur over time at the osteotomy site and the angle of inclination (neck-shaft angle). Inclusion criteria were a minimum of 2 years of radiographic follow-up. Patient follow-up ranged from 2 to 7 years (average 5.3 years). Goniometric measurements were performed at the osteotomy site as well as on the neck-shaft angle on preoperative, postoperative, and yearly AP radiographs. Results were recorded with reference to the percentage of correction per year. The authors also compared the results of patients younger than 8 years of age (group 1) with those older than 8 years of age (group 2). The average percentage of remodeling at the osteotomy site was 60% at 6 years, with 40% of the correction occurring within the first 2 years. The neck-shaft angle remodeled in a similar fashion: there was approximately two-thirds correction by 7 years, with most correction being evidenced within 3 to 4 years. There was no significant difference in remodeling based on the age of the patient at presentation. In conclusion, radiographically significant remodeling is to be expected after femoral varus osteotomy despite the diseased proximal femoral epiphysis.

BackgroundThere are many methods of treating Legg–Calvé–Perthes disease, including operative and nonoperative methods. Femoral varus osteotomy is one of the surgical methods used to treat this disease, and it involves changing the alignment of the proximal femur to improve containment of the femoral epiphysis in the acetabulum. The aims of this study were to evaluate the results of femoral varus osteotomy for the treatment of Perthes disease according to various classification and grading schemes, as well as to compare the results to those obtained using other methods of treatment reported in the literature.Materials and methodsTwenty-three patients with Legg–Calvé–Perthes disease were treated using a proximal femoral varus osteotomy procedure. The mean age of the patients was 7.8 years (range: 6–11.5 years). The average follow-up was 36.2 months (range: 29–48 months).ResultsThe patients were classified and graded according to the Catterall and Herring classifications. The preoperative and postoperative mean epiphyseal extrusion indices were as follows: group III (B), 10.88 % and 7.22 %, P = 0.027; group III (BC), 15.81 and 8.93 %, P = 0.005; group IV (C), 72.64 and 39.44 %, P = 0.018. The preoperative and the postoperative mean Wiberg’s CE angle were as follows: group III (B), 26.88° and 37.81°, P = 0.028; group III (BC), 24.4° and 32.2°, P = 0.005; group IV (C), 20.89° and 28.41°, P = 0.018. Changes in Iowa clinical hip scores were as follows: group III (B), 54.8 to 92.33, P = 0.027; group III (BC), 47.3 to 87.8, P = 0.005; group IV (C) 34.43 to 68.29, P = 0.017. In the last follow-up, the mean limb length discrepancy after plate removal was 0.9 cm (range: 0.0–2 cm) of shortening on the operated side. The author of the present study did not see any progressive change in this parameter during the follow-up period, especially after hardware removal and in the younger boys. All of the osteotomies united within 3 months without loss of fixation.ConclusionAccording to the results of the present study, proximal femoral varus osteotomy gives good results in children between the ages of 6 and 10 years without any femoral head deformity and flattening, especially with good containment in abduction.Level of evidenceLevel IV.

BackgroundStandard treatments may provide adequate containment in mild to moderate Legg-Calve-Perthes disease (LCPD), but they can be problematic in more severe cases. The purpose of this study was to report the results of combined shelf acetabuloplasty with femoral varus osteotomy in severe LCPD.MethodsWe reviewed 12 patients who had undergone combined shelf acetabuloplasty with femoral varus osteotomy. The indications for this type of operation were: (1) above 8 years of age at clinical onset; (2) massive femoral epiphysis involvement (Catterall group 4, lateral pillar C); (3) femoral head lateral subluxation on the anteroposterior radiograph; and (4) impending hinged abduction on preoperative magnetic resonance imaging or arthrography. The mean age was 9.3 years (range, 8 to 10.8 years). The patients were clinically evaluated with Iowa hip score and leg length discrepancy at the final follow-up. Radiographic outcome was assessed using the Stulberg classification to evaluate femoral head sphericity. The presence of osteoarthritis was evaluated by the Tonnis classification. Correlation analysis was conducted to analyze the preoperative factors that were strongly associated with patients' outcomes.ResultsThe mean follow-up period was 10.1 years (range, 7.1 to 13.2 years). Functional grade was excellent in all patients at last follow-up (mean, 92; range, 82 to 99). The mean leg length discrepancy after skeletal maturity was 0.9 cm (range, 0 to 1.7 cm). There were no significant complications or need for additional surgery. Radiographically, 92% of patients reached satisfactory outcomes: Stulberg grade I, 0 cases; Stulberg grade II, 4 cases (34%); Stulberg III, 7 cases (58%), Stulberg IV, 1 case (8%); and Stulberg V, 0 cases. There was no osteoarthritis by Tonnis classification.ConclusionsThe surgical outcomes for combined shelf acetabuloplasty with femoral varus osteotomy in severe LCPD patients over 8 years old are comparable with other advanced surgical methods. In the cases of severe disease that match our inclusion criteria, our containment method could be another treatment option.

In this retrospective observational study, I aimed to report long-term follow-up results of femoral varus osteotomy in the treatment of Perthes disease patients who were between 6 and 8 years old at the onset of the disease with Herring B and C hip involvement. I also aimed to compare 2 different osteotomy techniques: open-wedge and closed-wedge femoral varus osteotomies.Patients with Perthes disease treated with femoral varus osteotomies were invited for final examination. Twenty two hips of 19 patients were evaluated. Mean follow-up period was 15.2 years. Patients were divided into 2 homogenous groups according to femoral osteotomy technique. In Group A (12 hips) open-wedge osteotomy, and in Group B (10 hips) closed-wedge osteotomy was performed.There were 15 male (78.9%) and 4 female (21.1%) patients. The median age at the onset of the disease was 7 years in Group A and B. The mean follow-up period was 16.2 years in Group A, and 11.4 years in Group B. According to Stulberg classification 5 hips (22.7%) were healed as Class I, 4 hips (18.2%) were healed as Class II, 12 hips (55.5%) were healed as Class III, and 1 hip (4.6%) was healed as Class IV. Also in Group A 4 hips (33.3%) were healed as Class I or II, 7 hips (58.3%) were healed as Class III, and 1 hip (8.3%) was healed as Class IV; in Group B 5 hips (50.0%) were healed as Class I or II, and 5 hips were healed as Class III (50.0%). There was no significant difference between the groups. According to Iowa scale, mean values were 92.6 in Group A and 92.4 in Group B. There was no significant difference between the groups. At the final follow-up mean center-edge angles of Group A and B were 16 and 22, the difference was significant.Long-term follow-up results showed that femoral varus osteotomy was an effective treatment method in Perthes disease patients who were between 6 and 8 years old with Herring B and C hip involvement at the onset of the disease. Hip joint congruency was obtained with femoral varus osteotomies, and closed-wedge osteotomy served more favorable center-edge angle results.

We analyzed at skeletal maturity the radiographic results of 46 patients with unilateral Legg-Calvé-Perthes disease (LCPD) who were treated with femoral varus osteotomy (FVO) with special attention to proximal femoral growth. In 30 patients, leg-length discrepancy (LLD) and alignment change in the leg also were examined. The postoperative femoral neck shaft angle (FNSA) was not related to the result on Stulberg's criteria, but the postoperative acetabulum head index (AHI) was. Trochanteric prominence remained on the affected side in spite of an improvement in FNSA. LLD did not depend chiefly on FVO itself. The alignment of the leg on the affected side showed a tendency to valgus, which occurred to correct the mechanical axis displaced medially by the FVO. Along with an FVO for LCPD, some additional operative technique should be performed to prevent trochanteric prominence and medial displacement of the distal fragment to prevent genu valgum.

Though there is an impression that proximal femoral varus osteotomy (FVO) can result in a valgus deformity at the knee there is no agreement on this issue. This study was undertaken to ascertain whether a FVO predisposes to the development of genu valgum in children with Legg-Calvé-Perthes disease (LCPD). One hundred and one children with unilateral LCPD who underwent a FVO during the active stage of the disease and 32 children who were treated non-operatively were followed till skeletal maturity. The FVO was performed with a 20° varus angulation in all the patients and weight-bearing was not permitted till the stage of reconstitution. The alignment of the knee was assessed clinically at skeletal maturity. A subset of 33 operated children also had full length standing radiographs of the limbs. The mechanical axis deviation, femur-tibial angle, lateral distal femoral angle and the medial proximal tibial angle of both limbs were measured on these radiographs. The frequency of clinically appreciable mal-alignment of the knee was not greater on the affected side in patients who had undergone FVO when compared to the unaffected limb and also when compared to the affected limb in non-operated patients. The mechanical axis of the lower limb of operated children was relatively in more valgus than that of normal limbs but they fell within the normal range. This study does not support the impression that a proximal femoral osteotomy for LCPD predisposes to clinically discernable degrees of genu valgum in children who have had 20° of varus angulation at the osteotomy site and who have avoided weight-bearing for a prolonged period following surgery. Further studies are needed to clarify if genu valgum would develop if early post-operative weight-bearing is permitted. III.

The aim of this study was to evaluate the outcome at skeletal maturity of combined pelvic and femoral varus osteotomies in children with Legg-Calvé-Perthes (LCP) disease. From January 1998 to December 2009, 69 patients with LCP disease underwent combined osteotomies at our institution. Fifty-two children (19 girls and 33 boys) met the inclusion criteria and were enrolled in the study. The LCP disease was classified and the cases of all patients were reviewed at skeletal maturity. The mean age (and standard deviation) at the time of diagnosis was 6.9 ± 2.4 years, and the mean age at the time of surgery was 7.9 ± 2.3 years. The mean time to follow-up was 10.8 ± 3.5 years. The final follow-up radiographs were assessed according to the Stulberg classification and the sphericity deviation score. The mean Harris hip score at the time of follow-up was 90 ± 13.2. According to the Harris hip score grading system, 37 patients (71%) had an excellent outcome; 8 patients (15%), a good result; 3 patients (6%), a fair result; and 4 patients (8%), a poor result. Seven patients (13%) were classified as having a Stulberg class-I hip; 20 (38%), a class-II hip; 15 (29%), a class-III hip; 6 (12%), a class-IV hip; and 4 (8%), a class-V hip. The mean sphericity deviation score was 24.4 ± 14.4 at skeletal maturity. There was a strong relationship between a younger age at diagnosis and better functional and radiographic outcomes. In the absence of a randomized study design, conclusions have to be drawn with caution. Combined pelvic and femoral osteotomies in these children with LCP disease did not result in better functional or radiographic outcomes compared with the historic results of Salter osteotomy or proximal femoral osteotomy alone. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.