Positive outcome reporting in orthopaedic literature.

LEGG-CALVÉ-PERTHES DISEASE: 100 YEARS

Background: Legg-Calvé-Perthes disease (LCPD) is an idiopathic pediatric hip disorder associated with avascular necrosis of the femoral head. Although there is no standardized and optimal treatment protocol for patients with LCPD, there are three primary treatment strategies: symptomatic treatment, nonsurgical containment using orthotic devices, and surgical containment.Objective: This study aimed to describe the demographic characteristics, management and outcome of pediatric patients with LCPD at our center between 2005 and 2015.Material and Methods: In this retrospective study, 23 patients with LCPD who represented all patients with LCPD treated at King Abdul-Aziz Medical City, Jeddah, Saudi Arabia between 2005 and 2015 were enrolled. Their demographic and clinical characteristics, treatment methods, and outcomes were evaluated.Results: Descriptive statistics showed that most of the patients were males (87.0%), with a mean age of 7.1±2.4 years. None of the patients had a family history of LCPD. Approximately two-thirds of the patients reported hip pain as the chief concern. LCPD was observed in the left hip in 60.9% of patients, the right hip in 21.7% of patients, and both hips in 17.4% of patients. Approximately half of the patients (55.3%) were treated with physiotherapy, and 10.6% were treated with orthotics. Despite that, 10 patients (43.4%) required surgical management after the conservative approach, and six of them underwent pelvic Salter innominate osteotomy.Conclusion: These results highlight the experience of a single center in managing patients with LCPD. Treatment was different based on patient age; non-surgical treatment, mainly physiotherapy, was predominant in younger children. However, regardless of the type of treatment, the earlier interventions have proven to provide better outcomes in patients with this health condition.

The standard evaluation of epiphyseal involvement in Perthes disease is lateral pillar classification. However, it needs to be compared with contralateral normal hip leading to limited use in bilateral disease. We, therefore, develop a ratio between epiphyseal height and metaphyseal width of affected hips to estimate lateral pillar involvement. This study aimed to assess the height-width ratio of the proximal femoral epiphysis in non-Perthes children, and to find the relationship between the height-width ratio and lateral pillar classification in Perthes disease. A cross-sectional study was conducted between 2009 and 2015. Phase I included children aged 2 to 15 years who did not have Perthes disease. Phase II included children aged 2 to 15 years who had Perthes disease. Other abnormal proximal femoral epiphysis was excluded. Lateral pillar height and metaphyseal width were independently measured twice by 2 assessors in each phase. Intraobserver and interobserver levels of agreement, height-width ratio and cut-off points to differentiate lateral pillar types were determined. There were 69 children (87 hip radiographs) who had non-Perthes hips, and 18 boys with Perthes disease (20 hip radiographs). Height-width ratio in the non-Perthes group increased from 0.38 to 0.48 at 2 to 10 years of age and remained constant until maturity. Average height-width ratio in lateral pillar A/non-Perthes hip was 0.47±0.05, lateral pillar B or B/C 0.32±0.05, and lateral pillar C 0.18±0.05. Intraobserver and interobserver level of agreements of height-width ratio in Perthes disease were 0.007 (95% confidence interval, -0.030 to 0.043) and 0.006 (95% confidence interval, -0.119 to 0.107), respectively. Cut-off values to differentiate lateral pillar A and B or B/C was 0.40, and to differentiate lateral pillar B or B/C, and C was 0.25 with 90% accuracy and area under receiver operating characteristic curve of 0.9. Height-width ratio is useful for grading severity in unilateral and bilateral Perthes disease. It has excellent reliability and validity with exact cutoff values to estimate lateral pillar classification. Level II-diagnostic study.

There are several treatment modalities for Legg-Calvé-Perthes disease (LCPD), self-limiting, avascular osteonecrosis of the femoral head in children. Most treatments focus on containment of the weakened femoral head, but there is no consensus on the best modality for severe LCPD. Therefore, we compared the effectiveness of all treatment modalities for severe LCPD. We searched the PubMed, Embase, and Scopus up until July 2021 for studies that investigated LCPD treatment effectiveness. A network meta-analysis was performed to examine the comparative effectiveness in terms of the ability to achieve radiographic spherical congruity of the hip joint after skeletal maturity. The risk ratio (RR) and 95% confidence interval (CI) of each treatment modality were estimated from both direct and indirect evidence. Treatment ranking was based on Surface Under the Cumulative Ranking curve (SUCRA). A total of 857 studies were identified and 34 comparative studies with 3718 affected hips comparing seven different LCPD treatment modalities were included. Compared with symptomatic treatment, combined osteotomy was the most effective modality (RR = 1.47, 95% CI 0.90 to 2.42, SUCRA = 0.8), followed by femoral varus osteotomy (RR = 1.31, 95% CI 1.06 to 1.60, SUCRA = 0.7), and Salter innominate osteotomy (RR = 1.25, 95% CI 0.95 to 1.65, SUCRA = 0.6). Combined osteotomy is the most effective procedure in terms of improving the spherical congruity of the hip joint in severe LCPD patients. However, the superiority of operative treatments seems to be limited to patients older than eightyears old.

Background: Legg–Calvé–Perthes disease (LCPD) is a rare avascular osteonecrosis of the proximal femoral epiphysis and typically occurs during the childhood growth phase. LCPD is a complex illness of unknown origin, which is considered the main difficulty in the study of this disease. Various theories on LCPD etiology have been proposed; however, no consensus has been reached about its origin. Our research objective was to evaluate the polymorphisms FVL rs6025, FVIII rs5987061, FIX Malmö rs6048, PAI-1 rs1799889, eNOS rs17899983/rs2070744, IL-23R rs1569922/rs154655686/7539625, and TNF-α rs180062, and their relationship with LCPD. Methods: A blood sample was taken from each study participant. Complete blood count, coagulation times and factors, antithrombotic proteins, and homocysteine (Hcy) were determined using a coagulometric method. DNA was obtained and genotyped using real-time PCR with TaqMan probes. Genotypic and allelic distributions were analyzed using comparative analysis, the Hardy–Weinberg equilibrium, and OR. Results: This study included 46 children: 23 with LCPD (cases) and 23 without (controls). Statistically significant differences were found in Prothrombin Time, Factor V, and Factor IX activity, as well as Hcy concentration; these values suggest the presence of hypercoagulable states in patients, which can cause thrombotic events. On the other hand, significant differences were also found in the neutrophil–lymphocyte ratio and systemic immune-inflammation index, showing major inflammation states in the patient group. Moreover, statistically significant differences were found in the IL-23R rs1569922 polymorphism; it was found that carriers of the T/T and C/T genotypes have an increased risk of developing LCPD. Conclusions: Our results show greater hemostatic activity and inflammation in the group of patients included in this study, supporting various theories previously proposed. Therefore, we believe that LCPD is a multifactorial condition in which hemostatic, inflammatory, and genetic factors play a central and triggering role in the disease.

Multicenter study for Legg-Calvé-Perthes disease in Japan

Introduction: Legg-Calve-Perthes Disease (LCPD) is a condition characterized by ischemia of the proximal femoral epiphysis, leading to pain, limping, and potential hip joint deformities in children. Its etiology remains unclear, with theories implicating repetitive microtrauma, skeletal retardation, and vascular insufficiency. Diagnosis involves radiological assessment and classification systems to monitor disease progression, influencing treatment decisions and long-term outcomes. Material and methods: This study summarizes existing literature and clinical data on LCPD, focusing on etiological theories, diagnostic methods, treatment strategies, risk factors, and prognostic indicators. Information was gathered from medical databases, peer-reviewed journals, and case studies to compile a comprehensive overview of the disease. Aim of study: The aim was to gather current knowledge on LCPD, emphasizing diagnostic approaches, treatment modalities, and factors influencing clinical outcomes. Special attention was given to discussing the efficacy of various treatment options and identifying prognostic factors that impact the disease trajectory. Conclusion: Effective management of LCPD hinges on early diagnosis, appropriate treatment selection, and careful monitoring of disease progression. Prognosis is influenced by factors such as age at diagnosis, extent of femoral head involvement, and maintenance of hip joint congruence. Further research is needed to refine treatment protocols and improve long-term outcomes for affected children.

Legg–Calvé–Perthes (LCP) disease, sometimes shortened and referred to as Perthes disease, represents idiopathic necrosis of the proximal femoral epiphysis in skeletally immature children. It should be differentiated from avascular necrosis due to sickle cell disease, leukemia, and corticosteroid administration which can produce similar imaging findings. While it is generally accepted that an interruption in the blood supply to the immature femoral epiphysis is the underlying cause of the disease, and although several risk factors have been proposed, the ultimate etiology for this disruption in blood supply is unknown. Osteonecrosis of the immature femoral epiphysis can eventually cause fragmentation and deformity of the femoral head, including flattening of the femoral head (coxa plana), widening of the femoral neck (coxa magna), acetabular dysplasia with labral degeneration, and intra-articular or extra-articular CAM femoroacetabular impingement. Epiphyseal and acetabular deformity lead to decreased containment of the femoral head within the acetabulum and early hip osteoarthritis. The ultimate goal of treatment therefore is to prevent progressive femoral head deformity and maintain femoral head containment [1]. In most cases symptoms improve or resolve in childhood and prognosis is good in early adulthood, but increased incidence of hip osteoarthritis and need for hip replacement is noted in adulthood [2–6].

Legg-Calve-Perthes disease (LCPD) is a common hip disorder in children characterized by avascular necrosis of the proximal capital femoral epiphysis. The underlying etiology of the vascular disturbance is still unknown, but it is suggested that LCPD may be a part of a generalized constitutional disorder associated with growth disturbance of bone and cartilage tissue. In this study, the biopsy specimens of the iliac crest apophysis from LCPD patients were examined histologically and ultrastructurally to determine preexisting generalized abnormalities of endochondral ossification. Iliac crest apophysis cartilage was taken during Salter innominate osteotomy from 11 children (8 boys and 3 girls) with LCPD at an average age of 7.8 years. As controls, the samples were also obtained from 10 children (2 boys and 8 girls) at an average age of 6.3 years undergoing Salter osteotomy due to residual acetabular dysplasia after reduction of developmental dysplasia of the hip. Each iliac crest apophysis specimen was examined histologically (Toluidine blue staining and Sudan III staining) and ultrastructurally. Although there were no obvious differences in Toluidine blue-stained sections of the iliac crest cartilage between LCPD and control patients, the Sudan III-positive chondrocytes in the resting cartilage were more prominent in the LCPD specimens than in the control specimens. These sudanophilic granules were confirmed to be lipid droplets by electron microscopic examinations. Ultrastructural examinations of the resting chondrocytes from 3 LCPD patients demonstrated numerous cytoplasmic inclusion bodies with electron dense materials, which were similar to those seen in some of the mucopolysaccharidoses. Increased lipid droplets and numerous cytoplasmic inclusions filled with fibrillar materials were suggestive of the initial metabolic changes of the chondrocytes, which may have a pivotal role in degenerating matrix and lead to vulnerability of the cartilage tissue. Our results indicated that generalized insufficiency in growth cartilage metabolism may be related to the onset of the disease in some LCPD patients.

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.

Background: Perthes disease is a form of juvenile idiopathic osteonecrosis characterized by temporary bone mortality due to inadequate blood supply to the femoral head. Objectives: This cross-sectional study aimed to evaluate the treatment outcomes and sequelae of Perthes Disease and to identify the most effective treatment modalities for managing its sequelae. Methods: The research enrolled 59 Perthes Disease patients who had completed treatment at our institution between 2021 and 2022. The information pertaining to demographic characteristics, clinical presentations, radiological findings, specific treatments administered, and follow-up records were collected. Pain levels and hip functionality were secondary outcome measures. The Harris Hip Score (HHS) was used to assess the primary outcome of quality of life. Practical Implication: The practical implications for treating the sequelae of Perthes disease include early detection, a multidisciplinary approach, conservative management, surgical interventions when necessary, rehabilitation and physical therapy, long-term monitoring, and patient and family education. Timely diagnosis, collaboration among healthcare professionals, tailored treatment plans, and regular follow-up are important for optimizing outcomes and managing the condition effectively. Results: The average age of the study population was 4.76+1.10 years, with a higher proportion of males. Left-sided (59.32%) participation was more prevalent than right-sided (37.28%) participation (p<0.05). The disease's duration differed between patients. The majority of participants exhibited clinical symptoms such as hip or groin pain, limping, restricted hip movement, and deformities. The most prevalent treatment modality (p<0.05) was physical therapy (52.54%), followed by orthotic devices (30.50%) and surgical interventions (16.94%). Surgical procedures employed both extra-articular (70%) and intra-articular techniques (10%) (p<0.05). Conclusion: Multimodal, patient-specific approach is essential for managing Perthes disease sequelae. Physical therapy was the primary modality of care, while surgical interventions were employed selectively. Significant improvements were observed in pain reduction, functional outcomes, deformity correction, and ROM as a result of the treatment. These findings provided important insights into the management of Perthes disease and highlighted the need for individualized treatment strategies to achieve optimal patient outcomes. Keywords: Harris Hip Score; Perthes Disease; Orthopedic deformities; Orthotic devices; Radiological examination.

Legg – Calve – Perthes disease (LCPD) is the most common femoral head osteonecrosis in children. Until now, the knowledge of etiology, pathogenesis and clinical signs is partial and does not provide a coherent view of the disease. Despite modern advances in understanding and diagnosing of the disease, surgical interventions and stress release remain the standard treatment methods. Now there is a need to develop both new strategies for studying the pathogenesis of the disease and choosing methods of its treatment.The aim. Reproduction and development of morphological criteria for the early stage of Legg – Calve – Perthes disease (stages 1–2 by the modified Waldenström classification system).Materials and methods. The research involved 6 young gray giant rabbits (Flandres) aged 3–4 months. The early stages of LCPD were simulated by the pathophysiological model of Kuzhelivsky I.I. et al. (2016) with paraarticular adrenaline injections along with physical activity. We modified the physical activity regime for the subjects by daily free range for 1.5–3 hours.Results. The experiment confirmed the validity of the modified simulation and designed its morphological criteria. The osteochondropathy process was verified histologically, we also revealed the classic signs of damage to subchondral bone and hyaline cartilage as well as abnormal vascularization of cartilage sites and pathological neoangiogenesis.Conclusion. The technique of non-traumatic osteonecrosis simulation in young rabbits featured initial results in reproducing the pathological links of osteonecrosis process. The cartilage tissue featured the loss of isogeneity in chondrocytes structure and their column-like arrangement; its delamination and replacement with fibrous tissue, including fibroblast-like cells and collagen fibers; cartilage neovascularization and persistent mixed hyperemia. In the bone marrow, only the activation of the red blood cell line was noted. The bone tissue featured the abnormality of osteon structure with a mosaic arrangement of trabeculae as well as lacunar resorption, and osteoblast degeneration.

Perthes disease may result in deformity of the proximal femoral epiphysis and incongruity of the hip, and shelf acetabuloplasty has been frequently used for treatment. The aim of this study was to review the published articles about the outcome of shelf acetabuloplasty as a containment or reconstruction-salvage procedure in Perthes disease. We utilized the PubMed online database for peer review articles using the following search terms: shelf arthroplasty, acetabuloplasty, and Perthes. To be included in this meta-analysis, we isolated studies on children with Perthes disease who received shelf acetabuloplasty as a treatment, conducted in any geographic location with the Stulberg classification outcome. Twenty articles were identified for a qualitative systematic review. The fixed effect and random effect meta-analysis were performed as appropriate for the summary pool estimate following the heterogeneity test. The meta-analysis was performed on 11 articles in three categories: all articles, articles for shelf arthroplasty in the early stages of Perthes disease, and in the late stages. Overall, shelf acetabuloplasty provided 84% good outcome of Stulberg classes I, II, and III. Shelf acetabuloplasty performed in early stages for containment provided good outcome in 85%, while only 69% good outcome was achieved when shelf acetabuloplasty was performed in late stages for reconstruction-salvage. Shelf acetabuloplasty provides a good or fair Stulberg outcome when performed in early Perthes stages (Waldenström stages I and II) as a containment surgery, but less favorable outcomes were observed when shelf surgery was used for reconstructive-salvage purposes in late Perthes disease stages (Waldenström stages III and IV). Caution is advised in performing the shelf procedure in children over 10-11years of age.

Treatment methods in Legg-Calve-Perthes disease (LCPD) have varied during the 100-year history of this disorder. This is a review of the present practice of bracing in LCPD. Published articles from the last 35 years were reviewed including primary analyses of bracing, meta-analysis, and summaries of present opinion. The recent literature was also evaluated to determine the present bracing practices. Studies performed regarding specific braces failed to show that they offer any advantage over other methods of management, including no treatment. Similarly, meta-analyses showed that hips treated with nonoperative containment had little difference in outcome based on present methods of analysis. Opinion papers suggested that the use of braces in LCPD should be significantly decreased or discontinued altogether. There is a major controversy regarding weaning and discontinuation of bracing. The use of Petrie casts can be considered in "salvage" techniques of hips with subluxation or hinged abduction. The present literature does not provide evidence sufficient to support the use of bracing in LCPD. On the basis of this review, our recommendation is that the abduction orthosis should rarely be used in the treatment of LCPD. Petrie casts still have a role in short-term treatment in patients with deformed femoral heads before complete reossification.

Legg-Calve-Perthes disease (LCPD), in its severe form, remains a challenge. More recent classifications, particularly the modified Elizabethtown classification, have highlighted the chronologic stage of LCPD and its effect on surgical outcome. Hip severity and age of disease onset have also been shown to be powerful determinants of outcome. This study was performed to determine whether disease stage, disease severity, or patient age, are absolute indicators of whether a patient can benefit from surgical containment with triple innominate osteotomy (TIO). All patients with LCPD treated with TIO between 1995 and 2011 were collected. Only those patients with a minimum of 2-year radiographic follow-up and no previous or concomitant femoral realignment surgery were included. Fifty-four patients (56 hips) met our inclusion criteria. The modified Elizabethtown classification was used to classify disease stage as early (<IIb) or late (≥IIb). Catterall and lateral pillar classifications were used to classify disease severity, and the Stulberg classification was utilized for radiographic outcome, defined as good (I/II) or poor (III/IV/V). Fifty-one males and 3 females with a mean chronological age at surgery of 8.2±1.8 years were included (2 bilateral cases). Mean follow-up was 72.8±30.2 months. There was no significant difference in the proportion of Stulberg good versus poor outcomes when comparing hips that were graded as early or late stage (P=0.842), or Catterall I and II versus III and IV (P=0.304). Although not statistically significant, patients with lateral pillars B and BC (P=0.076) and patients who were aged 8.0 and younger trended toward doing better compared with lateral pillar C and over age 8.0 (P=0.085), respectively. Radiographic results demonstrate that good outcomes are not entirely dependent on the stage of disease in LCPD when containment is performed with TIO. As expected, TIO appears to be more effective in younger patients with less severe disease. We conclude that even severely involved LCPD hips, independent of age, should be offered surgical containment. The failure rate in this group is higher, as expected, but many achieve good results and there are treatment methods available to those who fail containment. Level IV.